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TEXTBOOK
OF PSYCHIATRY
BY
Prof. Dr. EUGEN BLEULER
DIRECTOR OF THE PSYCHIATRIC CLIKIC, ZURICH
AUTHORIZED ENGLISH EDITION

BY
A. A. BRILL, Ph.B., M.D.

FORMER ASSISTANT PHYSICtAN OF THE CENTRAL ISLIP STATE HOSPITAL AND ASSISTENZ-
ARZT OF THE CLINIC OF PSYCHIATRY, ZURICH. LECTURER ON PSY'CHOANALY'SIS
AND ABNORMAL PSYCHOLOGY, NEW YORK UNIVERSITY
THE MACMILLAN COMPANY

1934
/"S 2.
COPYBIGHT, 1924,
By the MACMILLAN COMPANY.

All rights reserved no part of this book may be
reproduced in any form without permission in writing
from the publisher, except by a reviewer who wishes
to quote brief passages in connection with a review
written for inclusion in magazine or newspaper.
Setup and printed. Published January, 1924.

Reprinted July, 1924; June, 1930. Reissued
January, 1934.
PRINTED IN THE UNITED STATES OF AMERICA BY

THE FERRIS PRINTING COMPANY, NEW YORK
^
TRANSLATOR'S PREFACE
When after about five years in the New York State Hospital I
entered Burgholzli, the clinic of psychiatry at Ziirich, I found a new
spirit in psychiatry there. Having been accustomed to look at pa-
tients through the eyes of the German psychiatry, as notably repre-
sented by Kraepelin, Professor Bleuler's ways impressed me not only as
more interesting but also as more instructive and farther reaching in
scope and result. Professor Bleuler was the first noted psychiatrist who
recognized the great value of Professor Freud's discoveries and im-
pressed his feelings on his co-workers.^ In Burgholzli the psychoanalytic
methods were applied to all accessible patients, and the Freudian
mechanisms were investigated even in the organic psychoses. This
resulted in many works of great importance which have exerted much
influence on psychiatry and psychopathology in general.
It was while I was Professor Bleuler's assistant, in 1907, that he
spoke to me about writing a textbook on psychiatry, and I volunteered
to put it into English. Since then I have translated a number of Pro-
fessor Freud's works and became closely identified with the psycho-
analytic movement, but my interest in psychiatry, through which I
first became acquainted with psychoanalysis, has remained just as
deep. It is therefore with a strong feeling of satisfaction that I present

this work to English readers.
This translation was made of, the author's fourth German edition,
and as far as was possible "the .German text was -strictly followed. The
only part omitted, was the addendum dealing witli forensic psychi-
atry. The autho-i:'s iêas are based on the Swiss, German/ and Aus-
trian laws which "are quite different' from: ours, and as"' ours are so
|
numerous, so- -indefinite and 'so contradictory it was thought' best to

omit this subject for the present.
This book was primarily written to furnish the student and the
general practitioner with a general knowledge of psychiatry-. The
author endeavors to present clear concepts, and whenever that is not
^The works of the Zurich school are too well known to be mentioned here.
For a complete bibliography of Bleuler's works the reader is referred to
^
Hans W. Maier's paper on Eugen Bleuler, Zeitschr. f. d. gesammte Neurologie

und Ps3'chiatrie, LXXXII.
7^77^
vi TRANSLATOR'S PREFACE
possible he lucidly exposes the existing gaps. He lays stress on the
understanding of psychology, because, to put it in his own words,
"psychiatry without psychology is like pathology without physiology,
and also because a good physician can be only he who understands the
whole human being."
Dr. George H. Kirby, Director of the N. Y. Psychiatric Institute,
and Professor of Psychiatry at the Cornell University Medical College,
who is most qualified to judge the development of psychiatric instruc-
tion in the United States, has rendered a great service by writing the
introduction. I am further indebted to him for many helpful sugges-
tions in the work of translation.
I owe gratitude also to Dr. M. S. Gregory, Director of the Psycho-
pathic Pavillions of Bellevue Hospital and Professor of Psychiatry at
N. Y. University Bellevue Medical College, and Dr. M. B. Heyman,
the Superintendent of the Manhattan State Hospital, New York City,
the former for his encouragement and valuable suggestions, and the
latter for a number of handwriting specimens of patients in his hospital.
A. A. Bhill.
November, 1923.
INTRODUCTION
The appearance of a translation of Professor Bleuler's textbook
will supply a need long felt by psychiatrists in English-speaking
countries. During his twenty-five years' service as a teacher at the

University of Zurich and Director of the Cantonial Hospital at Burg-
holzli Bleuler has been a most indefatigable worker and painstaking
investigator in the field of psychopathology and his numerous scien-
tific contributions and original observations have brought him inter-
national recognition as an outstanding leader in the progress of
modern psychiatry.
At least two of Bleuler's monographic studieshave already been
translated into English. His description and illuminating analysis of
negativistic phenomena was translated by Doctor William A. Whit^ in
1912 under the title of "The Theory of Schizophrenic Negativism." In
the same year another of his important studies, entitled "Affectivity,
Suggestibility, Paranoia," was translated by Doctor Ricksher. Ameri-
can psychiatrists also have had an opportunity to become acquainted
with another of Bleuler's important contributions, a summary' of which
he gave in an address on "Autistic Thinking" delivered at the opening
exercises of the Phipps Psychiatric Clinic, Johns Hopkins Hospital, in
1913. Those who had the pleasure of hearing and meeting Professor
Bleuler on that occasion were immediately charmed by his pleasing
personality and scholarly attainments, as well as impressed by his
ability to present a complex subject in clear and simple language and
to show by a penetrating analysis of symptoms how the ordinarily in-
comprehensible or illogical ideas and bizarre reactions of dementia
praecox had very plainly their counterparts in normal day-dreaming
and in childhood phantasy and play.
Of Bleuler's special studies, that on dementia praecox is generally
conceded to be the most important. This monographic work of over
400 pages was published in 1911 as one of the volumes of Aschaffen-
burg's Handbook under the title of "Dementia Praecox oder Gruppe
der Schizophrenien." Unfortunately this work has not been trans-
lated although the textbook which now becomes available in English
contains a comprehensive chapter on Schizophrenia (dementia praecox)
viii INTRODUCTION
with an admirable symptom-analysis, and psychological interpretation
of the development and course of the disorder.
The first edition of the textbook which appeared in 1916 was a
crystallization of Bleuler's long experience as a teacher and investi-
gator and contained a systematic presentation of his important
psychopathological formulations and their application in clinical
analysis. The warm reception accorded the book is attested by the
fact that four editions have already appeared.
The book marks a notable advance in psychiatry in that it em-
phasizes sharply the contrast between the older descriptive psychiatry
of Kraepelin and the newer interpretative psychiatry of the present
time which utilizes the psychoanalytical principles and general bio-
logical viewpoints developed by Freud and his pupils in Europe and
by Meyer, Hoch, White and others in this country. Bleuler was ap-
parently one of the first psychiatrists to grasp the great importance of
a psychodynamic viewpoint in the study of mental disorders and
as early as 1906 he published a paper on Freudian mechanisms in the
symptomatology of the psychoses. Although he became convinced
of the value and importance for psychiatry of many of Freud's for-
mulations, he has always preserved a well balanced and distinctly
independent attitude toward psychoanalytic theories and in the course
of his work he has not hesitated to criticize certain aspects of the
Freudian psychology.
As an introduction to the study of clinical psychiatry the physician
and the student will find the chapters dealing with the principles of
psychology and psychopathology particularly helpful and stimulating.
While Bleuler adheres to Kraepelin's general scheme of classification
of clinical types, it will be found that unlike Kraepelin he does not
stop with the mere enumeration of symptoms but seeks through the
application of psychological principles to give an interpretation and
explanation for the particular reaction type under consideration. This
applies not only to the so-called functional mental disorders and
psychopathic states but he also discusses most interestingly the psy-
chology and affective reactions of the toxic and organic syndromes.
Bleuler's book will be of interest and help to all those who wish
to advance beyond the formal descriptive psychiatry of a period now
rapidly drawing to a close. Teachers, practicing neuropsychiatrists
and state hospital physicians will find the book to be of great value and
assistance in their clinical work, as it will furnish them a comprehen-
sive presentation of the principles of modem psychiatry and their
practical application in a form not hitherto available in a psychiatric
textbook. It is a work which, as already intimated, marks a distinct
INTRODUCTION ix
advance beyond the boundaries of the Kraepelinian psychiatry. To

Doctor Brill, a former pupil of Blculcr's, the profession is indebted for
the successful completion of the difficult task involved in the trans-
lation.
George H. Kirby.
Psychiatric Institute,
Sept. 1, 1923.
CONTENTS
PAOK
Translator's Preface v
Introduction vii
CHAPTER
I Psychological Introduction 1
The Psychological Principles 1
The Psyche 1
Consciousness 2
Concerning the Theory of Cognition 3
The Unconscious 8
The Individual Psychic Functions 10
a) The Centripetal Functions 12
Sensations 12
Perceptions 12
b) Concepts and Ideas 13
Concepts 13
Ideas 16
c) The Associations, Thought 17
d) The Intelligence 23
e) Memory 28
/) Orientation 32
g) Affectivity 32
h) Attention 40
i) Suggestion 42
k) Dereistic Thinking 45
I) Belief, Mythology, Poetry, Philosophy 47
m) The Personality, the Ego 49
n) The Centrifugal Functions 50
II General Psychopathology 54
1. Disturbances of the Centripetal Functions 55

Disturbances of the Sensory Organs 55
Central Disturbances of the Sensations and
Perceptions (Hyperesthesia, Anesthesia, An-
algesia. Perception, Comprehension, Illu-
sions, Hallucinations) 56
xi
xii CONTENTS
PAGE
2. Disturbances of Concepts and Ideas 68
3. Disturbances of Associations and of Thought. ... 71
General Facilitation of the Psychic Processes.
Flight of ideas 71
Melancholic Retardation of Associations (In-
hibition) 74
Associations in Organic Psychoses 74
Schizophrenic (Dreamlike) Disturbances of
Association 77
Associations of Oligophrenics 82
Associations of Epileptics 82
The Associations of Hysteria 84
Associations of Neurasthenics 84
Associations of Paranoiacs 85
Other Disturbances of Association 85
Confusion 86
Diffuseness and Circumstantiality 86
Overvalued Ideas, Obsessions (Obsessive Acts) 87
Delusions 90
4. Disturbances of Memorj^ 97
5. Disturbances of Orientation 110
6. Disturbances of Consciousness Ill
Clear Mindedness (Besonnenheit) 116
7. Disturbances of Affectivity 117
Morbid Depression 119
The Pathological Elated Mood (Exaltation,
Euphoria) 122
Morbid Irritability 123
Apathy 124
Variable Duration of the Affects 124
Emotional Incontinence 125
Affective Ambivalence 125
Congenital Deficiency and Perversions of Par-
ticular Affective Groups 126
Exaggerations and Onesidedness of the Affec-
tive Causes, Morbid Reactions 126
Pathology of Affective Disturbances 131
8. Disturbances of Attention 133
9. Morbid Suggestibility 135
10. Disturbances of Personality 137
CONTENTS xiii
11. Disturbances of Centrifugal Functions (Actions,

Weakness of Will, Stupor, Inhibited Actions,
Akinesis, Hyperkineses, Stereotypes, Morbid
Impulses, Compulsive Actions, Katalepsie,
Negativisms, Inadequate Manifestations of
Affects, Speech Anomalies, Writing Anomalies) 142
III Physical Symptoms 157
IV The Manifestations of Mental Diseases 161

Morbid States 161
Syndromes 164
V The Course of Mental Diseases 167
VI The Borderlines of Insanity 170
VII Classification of Mental Diseases 173
VIII The Recognition of Insanity 184
IX Differential Diagnosis 193

Compilation of the Differential Diagnostic Signifi-
cance of Individual Symptoms 194
Disturbances of Perception 194
Disturbances of Association 195
Disturbances of Orientation 196
Disturbances of Memory 196
Affective Disturbances 197
Some Special Syndromes 198
X Causes of Mental Diseases 200
XI The Treatment of Mental Diseases in General 214
XII The Significance of Psychiatry 226
XIII The Individual Mental Diseases 230

L-V. The Acquired Psychoses with Coarse Brain
Disturbances. The Organic Syndrome .... 230
I. Insanity in Injuries to the Brain 240
II. Insanity in Brain Diseases 242
III. Syphilitic Psychoses 244
IV. Dementia Paralytica 250
V. Senile and Presenile Insanity (Senile Psy-
choses) 276
Presenile Insanity 279
xiv CONTENTS
PAGE
Arteriosclerotic Insanity 279
Senile Dementia (Simple Dementia Senilis) 286
Presbyophrenia 294
VI. The Toxic Psychoses 299
1. The Acute Toxemias 299
Pathological Drunkenness 300
2. The Chronic Intoxications 303
A. Chronic Alcoholic Poisoning 303
The Simple Drinking Mania ... 303
Delirium Tremens 326
Alcoholic Hallucinosis 341
Alcoholic Psychoses with Or-
ganic Symptoms 345
The Alcoholic Korsakoff Psy-
chosis 346
Alcoholic Pseudoparesis 350
Polioencephalitis Superior 350
Alcoholic Leukencephalitis of the
Corpus Callosum 351
Chronic Delusions of Jealousy in
Alcoholics and Alcoholic Para-
noia 351
Dipsomania 351
Alcoholic Epilepsy 353
Alcoholic Melancholia 354
B. Morphinism 354
C. Cocainism 359
VII. Infectious Psychoses 361
A. Fever Deliria 362
B. Infectious Dehria 363
C. Acute Confusion, Amentia 364
D. Infectious States of Weakness 365
VIII. Thyreogenic Psychoses 365
Psychoses in Basedow's Disease 365
Myxoedema (Cachexia Strumipriva) 366
Endemic and Sporadic Cretinism 367
IX. Schizophrenias (Dementia Praecox) 372
A. The Simple Functions 373
B. The Complex Functions 384
C. The Accessory Symptoms 387
.
CX)NTENTS XV
TAtm
D. The Subdivisions (Paranoid, Catatonia,
Hebephrenia, Schizophrenia Simplex) 413
E. The Course 434
F. What Is Included under the Term 436
G. Combination of Schizophrenia with
other Diseases 437
H. Diagnosis 438
I. Prognosis 440
K. Causes 441
L. Frequency and Prevalence 442
M. Anatomy and Pathology 442
N. Treatment 443
X. Epilepsy 445
XI. Manic-Depressive Insanity 465
XII. Psychopathic Forms of Reaction (Situation
Psychoses) 493
1. Paranoia 510
2. The Delusion of Persecution of the Hard
of Hearing 533
3. Litigious Insanity 533
4. Induced Insanity (Folie a Deux) 534
5. The Reactive Mental Disturbance of
Prisoners 535
6. The Primitive Reactions 537
7. Reactive Depressions and Exaltations. 537
8. The Reactive Impulses (Impulsive In-
sanity of Kraepelin) 538
9. The Reactive Changes of Character .... 540
10. The Neurotic Syndromes 540
A. Hysterical Syndrome "Hysteria".. 540
B. The So-Called Neurasthenic Syn-
drome. Neurasthenia and Pseu-
doneurasthenia 556
Actual Neurasthenia, Chronic Ner-
vous Exhaustion 557
The (Pseudo-) Neurasthenias .... 558
C. The Expectation Neurosis 560
D. The Compulsion Neurosis 560
E. The Accident Neuroses 564
XIII. The Psychopathies 569
A. Nervosity 571
xvi CONTENTS
CHAPTER PAGE
B. The Aberrations of the Sexual Impulse. 572
C. Abnormal Irritability 582
D. Instability 582
E. Special Impulses 586
F. The Eccentric (Verschrobene) 587
G. Pseudologia Phantastica (Liars and
Swindlers) 587
H. Constitutional Ethical Aberrations
(Enemies of Society, antisocial be-
ings, moral oligophrenics, moral
idiots, and imbeciles. Moral Insan-
ity) 587
I. The Contentious (Pseudo-Litigious) . . 591
XIV Oligophrenias (Psychic Inhibitions of Development) . . 593

ILLUSTRATIONS
P/l'.K
1. Paretic expression 251

2- Paretic expression 252
3. Paretic writing 253
4. Cortex in paresis 262
5. Normal cortex 264
6. Gliosis in paresis 265
7. Round cell infiltration 266
8. Plasma cells 269
9. Senile writing 291
10. Pyramidal cell in senility 293
11. Presbyophrenic 295
12. Cortex in presbyophrenia 297
13. Plaques in presbyophrenia 298
14. Plaques magnified 298
15. Normal cortical cell 299
16. Writing of a chronic alcoholic 305
17. Writing of a delirious patient 334
!^
18. Cretin 368
19. Two cretins in profile 369
20. Myxoedematous cretin 370
21. Cretin excitation 371
22. Hebephrenic 381
23. Catatonic 382
24. Hebephrenic writing 395
25. Schizophrenic writing 396
26. Paranoid praecox writing 397
27. Drawing by paranoid praecox 399
28. Letter of schizophrenic patient 401
29. From a note book of a chronic catatonic 402
30. Catatonic attitude 403
xvii
xviii ILLUSTRATIONS
Pig. page
31. Permanent catatonic attitude 404
32. Stereotyped attitude 405
33a and 33b. Snout cramp 406
34. Grimacing catatonic 408
35. Manic schizophrenic woman 409
36. Chronic catatonic women 421
37a. Manic writing 470
37b. Manic writing 471
38. MelanchoHc expression 472
39. Veragutii's fold of upper lid in depression 473
40. Normal fold 473
41. Writing of depressed patient 477
42. Mixed condition in constant euphoria 480
43. Imbecile somewhat microcephalic 605
44. Imbecile laughter 606
45. Pygrocephalus 607
46. Microcephalus 608
47. High grade microcephalic 609
48. Cerebral infantile paralysis 610
49. Idiot 612
50. Idiot 613
51. Microgeria in imbecile 614
TEXTBOOK OF PSYCHIATRY
TEXTBOOK OF PSYCHIATRY
CHAPTER I
PSYCHOLOGICAL INTRODUCTION
THE PSYCHOLOGICAL PRINCIPLES ^
The Psyche
The human psyche is so largely dependent in all its functions on
the cerebral cortex and on this alone that it is said to be located
there.^ But not all functions of the cerebral cortex belong to the
complex which we ordinarily call psychic.^ Thus what has been called
psychic fluctuations of the vascular tone or of the secretions are
cortically directed functions, which though depending on the psyche
in some manner are not psychic.
Like the reflex mechanism, the purpose of the psyche is to receive
external stimuli and to react to them in a manner beneficial to the
individual or the genus. There are, however, great differences between
the two modes of reaction. The influence exerted upon a reflex through
a stimulus other than the one initiating it (or the initiating and direct-
ing group of stimuli), is so limited qualitatively and quantitatively,
that we ordinarily take no account of it. On the other hand, in the
psyche this influence is qualitatively and quantitatively almost unlim-
ited. noteworthy that not only actual stimuli play
It is particularly
an essential part but also former stimuli,
in determining the reactions,
especially ''experiences" and "memories"; on the other hand, such
memory effects play a very slight part in the reflexes. In other words,
the reflex always reacts in the same manner to the same stimulus, while
the psyche has infinite possibilities of reaction, which are highly com-
plex and plastic, that is, they differ with the same stimulus according
^Comp. Naturgeschichte der Seele, Springer, Berlin, 1921.

Bleiiler
" In many
vertebrates evidently not all psychic functions have gone into
the cerebral cortex; that is particularly true of the lower ones. Even in man
there is still some connection between basal ganglia and affectivity.
* Contrary
to general assumptions, the line of demarcation between psychic
and non-ps.vchic cortical functions is quite indefinite. It is certain that
only small parts of the cortical functions are conscious. (Cf. Section on
"Unconscioua.")
1
2 TEXTBOOK OF PSYCHIATRY
to the particular circumstances, while those of the reflexes are simple
and very stable. Thus as far as objective conditions are concerned
the difference between reflex and psychic reaction is enormous in de-
gree,but none in principle. An absolute difference is ordinarily
assumed on the subjective side, whether correctly or incorrectly no one
can tell (Pflueger's spinal cord soul!) The assumption is that only
psychic functions can become conscious but not reflex:es.
Consciousness
Some authors consider consciousness as the very essential quality
of psychic processes. It is an indefinable something, a quality of the
same, in fact that quality which most clearly differentiates us from
an automaton. We
can imagine a machine which will perform com-
plicated reactions butwe will never ascribe consciousness to an ap-
paratus constructed by us, that is, we cannot assume that it ''knows"
what it is doing, that it "feels" the influences of its environment,
that it knows the "motives" of the reaction. The same idea is ex-
pressed by the word "conscious," when we inquire whether someone
has consciously or unconsciously arranged his hair.
To compare consciousness with a form which has for its content
conscious processes is misleading. Nor can one do anything in psycho-
pathology with such a definition as "the sum of all real or simultane-
ously present ideas" (Herbart), which is about what one would call
the actual psyche. We
cannot get along, however, without differ-
entiating between and unconscious psychic processes on
conscious
the one hand, and between psychic and physical on the other.*
Wundt defines consciousness as the "association of the psychic
structures." This definition is also used elsewhere in the concepts
referring to the "disturbances of consciousness," where it is merely a
question of a disturbance in the association of the psychisms. Con-
sciousness in our sense cannot very well be disturbed; it is either
present or absent On the other hand, extent and clearness of con-
sciousness are relative terms. The extent of consciousness corre-
sponds to the number of the (actually or possibly) simultaneously
existing conscious ideas, and clearness
of consciousness depends on
the completeness of one concept or on one idea of a
conscious
partially forming concept, as well as on the degree of exclusion of
irrelevant ideas.
The psychism itself and not a mere quality or form of it is
involved in expressions like "consciousness of time and place" for

which we had better substitute "orientation as to time and place."
* See pp. 7-8.
PSYCHOLOGICAL INTRODUCTION 3
The expression "dual consciousness" for "dual personality" is jut

as inappropriate.'^
Furthermore, one is inclined to assume consciousness in our sense,
when one observes purposive actions. This is not correct, for even
reflexes may be purposive; even an automaton may react differently
to different situations, as in the case of automatic scales in the mint.
The ability to remember a certain experience has often been con-
sidered as a sign that consciousness had been present, and it has
also been said that an action performed in a twilight state has been
"without consciousness." This is also wrong.
Likewise one should not identify "conscious" and "voluntary."
The act of dressing oneself
is usually voluntary, but not conscious,
whereas compulsive actions are conscious, but not voluntary, that is,
they are contrary to our will. And neither of these holds good in
automatic actions like scratching oneself, mimicking motions, etc. and ;
in pathological automatisms.^
Concerning the Theory of Cognition ^
Consciousness is said to differentiate psychic from physical occur-

rences. Two fundamentally different series of experiences have been
assumed, those that refer to the "inner life," to that which "takes place
merely in time," the conscious or the psychic, and those experiences
which refer to the outer world or to that which has extent, namely, the
physical.
The relationship between these two forms of experiences is dif-
ferently conceived. Most suitable for the naive mind is the conception
of Dualism, which assumes a carrier of consciousness independent of
the body. One sees the body remaining after death, while all psychic
manifestations disappear with the cessation of life. The "soul," used
here according to the earlier views, representing not only the psychic,
but a fusion with the term life, has separated itself from the body.
That it has not simply been resolved into nothingness is sho^Mi by
its reappearance in dreams, in waking hallucinations, and in the
illusions of those who survived. And that the observer's own soul
can free itself from his body is shown by his dream experiences, during
which, regardless of time and space, he perceives things which are
far removed from his motionless body.
^Disturbances of Personality, p. 137.

"The subject of "self-consciousness" uill be discussed at the end of the
chapter on personality, p. 50.
' Ziehen,
Zum gegenwartigen Stand der Erkenntnistheorie Wiesbaden, Berg-
mann, 1914,
Dualism is an essential constituent of religions ; it has been attacked
for thousands of years and is at present by most sci-
still rejected
entists. most important fundamental elements, the dream experi-
Its
ences, and the apparitions of spirits, have proven illusory, and what
is more, it has been shown that the psychic functions of man are in
all respects dependent upon the brain. On the other hand, it is self-
evident, even if one does not always bear it in mind, that in reality
the physical world cannot at all be as we perceive and imagine it,
and finally, every certain proof is lacking that iV even exists.
Thus monistic views have been formed regarding the relationship
of the two series. They can be divided approximately into three
categories:
The first of these categories, of which Spinoza is the foremost rep-
resentative, assumes a "substance," whose two attributes are exten-
sion (physical series) and thought (psychic series). However, from
the viewpoint of the cognitive theory, it is faulty. Substance, physical
and psychic modern tdrms matter, force and conscious-
attributes (in
ness) cannot be placed side by side in this manner. For direct per-
ception is possible only in regard to conscious (psychic) processes.
From a part of these we form conclusions (with some probability)
concerning external influences, which we call forces. From the group-
ing of forces we construct the idea of matter, which needs not neces-
sarily have a corresponding reality. But there is still another diffi-
culty in this theory: It has to conceive everything as conscious

whereas we observe consciousness only in beings similar to us and
cannot conceive of an elementary consciousness without content, which
is really connected with a nervous center. To be sure, nowhere in
evolution do we see a point where consciousness may be said to have
appeared in man? in the amoeba? or in the atom? ^ And the ubiquity
of consciousness is so readily accepted just because one cannot con-
ceive of something principally new suddenly appearing in evolution.
There is really no basis whatsoever for the assumption that the psychic
and the physical are so very different. We neither know v>'hat the
psychic nor what the physical processes are, and consequently nothing
about their relationship or difference. To be sure, for the being en-
dowed with feeling, consciousness is something very special and the
only thing of importance. It is a matter of entire indifference to
us whether the world exists, the only thing of importance being whether
that which is conscious, our ego, is happy or unhappy.
The second form of monism starts from the idea that all proofs
for the existence of an external world are false conclusions, and
Cf. also Loeb's tropisms.
that consequently the physical world exists only in our ideas f Idealism;
or, in so far as we conceive it ("esse = percipi"). Even if this view
could be carried through with logical consistency, it would not be
able to acquire a more general acceptance. For in the first place,
it is incorrect todeny the outer world simply because it is impos-
sible to prove its existence. Anyhow one is always forced to act
as if it exists. The philosopher who claims to believe in the ex-
istence only would have no reason for disseminating his
of ideas
views if his pupils were only creations of his own imagination. No
matter how certain it were that a rock in the road had existence
only in my imagination, I would still have to go out of its way if
I wished to avoid something unpleasant. If I wish to get rid of
the feeling of hunger, there is nothing for me to do except to eat,
whether food has reality or not. Practically therefore, idealism

will lead to an impossibility. Theoretically, however, it leads to
a conclusion which no one likes to accept, to Solipsism. For our fellow
beings are part only of the outer world, and if the outer world
exists only in my ideas, then there are no other beings beside myself.
/ am not only the whole world but also the only human being. This
conclusion is unavoidable. The attempt to escape solipsism through
the assumption of an absolute ego is a sophism. Even if an abso-
lute ego were to imagine the world, it would not be my world, the
world which I imagine, not to mention the fact that such an absolute
ego cannot be imagined and that the whole assumption is entirely
without foundation.
Much more common than the idealistic monism is the materialistic
monism, the materialistic theory of cognition. It starts from the
fact that we always see psychic functions bound to matter, in par-
ticular to nervous centres, that they change with this matter, and
that the laws of the central nervous processes, so far as they come
into consideration, are also the psychic laws. From this it con-
cludes that the psyche is a function of the brain. At present this
is the only view which can be carried out theoretically and prac-
tically without contradictions, in the form of the so-called hypothesis
of identity, which assumes that central nervous functions are ''seen
from within" and become "conscious" if they occur in definite rela-
tionships. This view is almost the only one which modern science,
and in particular psychiatry, takes into consideration, in fact it is
even accepted by those who theoretically advance another view. Of

course, this theory, too, is impossible to prove, but the hypothesis that
the psychic functions are brain functions has a better foundation
than most assumptions which are accepted as self-evident in the sci-
ences. But it is by no means necessary as a basis for any mental
science, including psychiatry, in so far as we are not concerned with
studying the psychic functions in connection with the brain. This
theory, too, is being zealously attacked, primarily on religious grounds.
Perhaps with the exception of its earlier periods Christian thought
has been altogether duahstic. But the essential content of the Chris-
tian doctrine could be just as easily reconciled with materialism as
with dualism; as a matter of fact the more favored idealism would
encounter more diflBculties. Our confession of faith contains the doc-
trine of the resurrection of the body. If the theory of materialism
is correct, then with the resurrection of the body the soul must also
eo ipso be resurrected at the final judgment. Difficulties arise only
in connection with secondary doctrines like those of purgatory, the
existence of bodiless souls, etc. Moreover, partly as a result of un-
clear thinking and partly from rancor, the materialism of the cogni-
tive theory is usually identified with ethical materialism, which, re-
gardless of morality and consideration for other people, egoistically
strives merely for ''material" goods, by which is meant money, posi-
tion, good food, drink, and women. But the materialism of the
cognitive theory has nothing in common with such ideas except its
name. One may accept any view of the cognitive theory and still
be either good or bad. But on the basis of the materialistic view,
one can deduct a utilitarian ethics by strict logical reasoning, which
is superior to all other, which professes to have originated from
revelation or the categorical imperative, or from other incomprehen-

sible eternal laws, and which at the same time can be fashioned by
every one according to his own desire.
Many modern scientists hold to the theory of psycho-physical
parallelism. This theory starts from the idea that both series are
so heterogeneous in principle that one cannot act upon the other.
To explain this relationship nevertheless, Ceulincex assumed that if
the psyche wished to perform a physical movement, it was accom-
by an interposition of divine power, and that every
plished in each case
time a stimulus strikes the sensory organs the corresponding sensa-
tion is produced in the psyche (Occasionalism) Leibniz, as is well
.
known, held the view that these two series (which were complicated
by his theory of monads) were so arranged by preestablished harmony,
since the beginning of creation, that they run an entirely uniform
course like two ideal watches, so that every act of the will has a corre-
sponding equivalent movement, and every stimulus on the senses a
corresponding equivalent sensation. But this theory of psycho-phys-
ical parallelism contains one great error: For if the physical series
cannot react upon the psychic then it can reveal neither its existence
nor its nature to our psyche. It is then quite useless to assume that
the outer world exists, at any rate it surely does not exist as we
think we perceive it, and then there is no perception, but only
hallucination.
The concept still have some meaning within
of parallelism could
monistic conceptions inasmuch as the conscious side of
(Spinoza)
the substance has knowledge of the physical part which is really sub-
stantially identical with it.
Many view psycho-physical parallelism simply as a confirmation

of our ignorance regarding the relationship which undeniably exists

between the psychic and physical sometimes, and this is particularly
;

true of experimental psychology, with the secondary thought that
we must examine what processes correspond to each other in the two
series. This view is also possible, but the name, which is otherwise
used quite differently, easily leads to confusion. Some clinicians,
without realizing it, get still further away from the original idea,
when, for instance, they consider hysteria as a disturbance of the
psycho-physical parallelism, because the psychic reaction to the ex-
periences becomes too strong or too weak. Here, of course, the
physical "parallel processes" in the brain certainly correspond to the
psychic phenomena. In this case therefore the expression is highly
misleading.
Wundt has assumed a peculiar view concerning the psycho-physical
parallellism. Like many others, he does not only limit the psychic
series to the brain functions, but also makes the psychic go beyond
the physical, by assuming that certain synthetic functions of our
mind take place in the brain without parallel processes. This is an
inconsistency which is not only impossible to prove, but which, among
other things, is opposed by the fact that we have an analogous
synthesis in the physical sphere. Many reflex processes are the
result of a whole group of stimuli, which act only as a unit. Like-
wise the performance of a complicated machine is not equal to the
simple sum of the effect of the individual constituents, at least if sum
and constituents have the same meaning as in Wundt's synthesis.
In the dispute between idealism and materialism one senses an
uncertainty regarding the value of reality of these two series. But
if one only follows up the thought, this question can be very' easily
settled. Only its own psychic processes have absolute reality for
every psyche (it is not in their "contents," i.e. we perceive the
light or the rose, but not the light, the rose) . If I feel a pain. I feel
the pain. This is so certain that it can only be expressed tauto-
logically. Since there are also hallucinated pains, this pain need not
necessarily have a corresponding process in the aching part of the
body. But a skeptic does not wish to believe that I feel pain, it
if
will be impossible forme to prove it. The psychic series therefore

has absolute, or better, indisputable reality, but only for the psyche
in question. This reality is therefore subjective. But for the ex-
istence of the external world there are no proofs. That the table
which we see has existence is only an assumption, even if of prac-
tical necessity. But if I once take for granted the existence of the
table, and that of other people, and the external world, then this
table can be shown to these other people. Like myself they can per-
ceive it with their senses. The reality of the physical world is
therefore uncertain and relative, that is, it is not possible to prove it,
but on the other hand, it is objectively demonstrable.^
The Unconscious
We perform many trivial actions, such as stroking our hair, un-
doing a button, shaking off an insect, without knowing it. To a large
extent these are neither reflexes, nor subcortical actions, but actions
which are performed by the cerebral cortex and are really analogous
to conscious functions. Such acts also presuppose memories. "Auto-
matic" actions in hypnotic experiments and in pathological states
can be just as complex in thought and motility as any conscious act.
The hand may write and the mouth speak without the person hav-
ing the slightest feeling that these actions originate from his own
psyche. In association experiments the train of thought often goes
by way of ideas which are not conscious. The answer to "black"
may be "star" without there being any conscious thought of "night"
which forms the connecting link. As a matter of fact, the con-
stellations which direct our thought are only conscious to a small
degree, as amore detailed analysis shows; we often make slips in
speaking which are based on unconscious thoughts accompanying
it. Only a small part of what our senses perceive comes into con-
sciousness, but the rest surely is not lost to our psyche. Thus, in
walking we constantly guide ourselves by perceptions which do
not become conscious. Many perceptions come into consciousness
only later on. Thus, when one is very busy, he may not hear the
striking of a clock, but when the attention is relaxed it is so well
Psychoanalysts also differentiate a "psychic reality." This term is mis-

leading, for they refer to ideas which are created by inner needs and are accepted
and used as if they corresponded to what we call reality (the dead child con-
tinues to live, the fire of love really bums, or the mediaeval personal God).
remembered that one can still count the strokes to about five. Other'
things become conscious in dreams and in the hypnotic state. Un-
consciously a number of complex conclusions are drawn; the so-called
intuition is partly based upon this. We may meet a person and
feel certain an acquaintance, but we arc surprised that we
that he is
do not evince the same feelings that we ordinarily have for him,
only to ascertain shortly afterwards that it is not at all the expected
person. Here, besides the conscious mistaken identification, there

was also present an unconscious correct one. The physician auto-
matically puts the correct key into the many different locks of his
hospital; but as soon as he wishes to do it consciously there are diffi-
culties. Signs of an affect are frequently seen in normal persons, and

daily in pathological conditions, of which the person affected has no
knowledge. And if we carefully observe ourselves and our fellowmen,
we will frequently find that just in important decisions the decisive
elements are unconscious. By post hypnotic suggestions we can
also experimentally provoke actions, the motives of which remain
hidden from the person performing them. Hysterical patients may
respond to perceptions of which they do not become conscious.
Everything that occurs in our consciousness can therefore also take
place unconsciously. In this sense there are unconscious psychic proc-
esses. They have absolutely the same value as the conscious psy-
chisms, as links in the causal chain of our thought and action. It
is therefore necessary them among psychic processes,
to include
not only because they have the same value as conscious ones,
lacking only conscious quality, but principally, because psychology',
and particularly psychopathology, can only be an explanatorj- science
if such important causes of the phenomena are also taken into
consideration.
The unconscious functions are best designated as "the unconscious.'^
But in the above described psychisms this does not imply a definitely
limited class of functions ; the real facts, however, are that potentially
any function whatsoever can manifest itself consciously as well as
unconsciously. Neither are there special laws for unconscious think-
ing; there are merely relative differences in the frequency of the
different forms of association.
To be sure one may place into a special unconscious the main-
springs of our strivings also hidden from our
and actions which are
introspection. This includes not only the congenital impulses but
also the unconsciously acquired paths of the strivings.^"
Such impulses are particularly striking when they are contrar\'
"Comp. The Collective Unconscious, p. 43.
to the conscious strivings through which they attain the same patho-
genic meaning as the repressed tendencies.
The unconscious also contains the paths upon which the psyche
influences our secretions, the cardiac vasomotor and other activities,
even if exceptionally they sometimes become conscious and are acces-
sible to the will in the same sense as we move our limbs consciously
*
and unconsciously.
Many authors, notably Freud, Morton Prince and others, include
among the unconscious functions also the "latent memory pictures"
("Engrams") ." But these are principally altogether different from
what we have here described. Latent memory pictures, in so far as
we are concerned here, are dispositions without actual functions, but
our unconscious psychisms are actual functions just as valid as
those that are conscious. We
can include among the psychic only
those functions which are conscious, or may become conscious under
different circumstances. It is for this reason also that we do not
designate the action of a machine as unconscious, although it has no
consciousness.
To understand the relationship between conscious and uncon-
scious it is best to assume that a function becomes conscious only
when it is in direct associative connection with the ego complex; if
this not the case, then it follows an unconscious course. This as-
is
sumption fits in well with all observations; nor does it run counter
to the fact that there are all the transitions from consciousness to
semiconsciousness and to the unconscious. The greater the number
of associative connections at a given moment between the ego and
the psychism (idea, thought, action) the more conscious and at the
same time the clearer is the latter.
What we call "unconscious" is designated by some as "subcon-
scious." Philosophers define the term unconscious quite differently;
it also varies in meaning in different authors.
THE INDIVIDUAL PSYCHIC FUNCTIONS

While taking a walk I stop and take a rest. Then I see a well
and I go over and drink some water. What has taken place in
my psyche?
The which strike my retina cause sensations, that is,
light rays
I see certain colors and lights in definite spatial arrangement. Some
of these groups I have already seen before in a corresponding com-
bination. As related units of a higher order they acquire a certain
^'See chapter on Memory.
independence and are rendered prominent as objects (trees, houses,

wells), and from former experiences I know that there is something
in the well which I call water which can quench my thirst. That is,
the "concept" of the well with all its essential elements has been
awakened in me, while the momentary experience has only given me a
number of color spots. This awakening of former similar sensory
complexes by the new sensation is a perception. I have a sensation
of certain light arrangements but I perceive certain objects, I have a
sensation of sounds but I perceive a speech or the bubbling of the
spring, I have a sensation of an odor, but I perceive the scent of violets.
As I am thirsty, I have an "impulse" to drink from the well. The
thirst and the impulse to drink are evidently also responsible for the
fact that the well was rendered more prominent than the numerous
other objects striking the eye. But I have not only the impulse to
drink, but I would also like to rest a little longer. It also occurs
to me that the water might be infected, that I will get a better drink
in the next inn, etc. Opposed to this is the thought that I don't
know how long I will have to walk until I get there. The source
region of the well does not look suspicious; the impulse to quench
my thirst therefore becomes the stronger of the two. I decide to
take a drink here, but to do it only after I have rested a little longer
and am ready to continue my walk. The different impulses with
the ideas accompanying them have provoked a play of thought, a
reflection, which finally had as its resultant the decision which at the
proper time led to action.
We have here as in other nervous functions a centripetal ^- recep-
tion of stimuli or of material, which we divide into sensations and
perceptions, and then an elaboration and a partial transformation
of the material into centrifugal functions (decision, actions). It is
perhaps only to a very slight degree, if at all, that there is an
elaboration sufficient to lead the incoming psychokym ^^ by preformed
mechanisms into centrifugal paths, a process surely not quite cor-
rectly assumed in the reflexes. Here the elaboration occurs in such
" I do not speak of "psychopetal" functions, because although there is a given
"direction" yet both incoming and outgoing functions, as far as psychology' is
concerned, take place within the psyche. It is well, however, to understand by
"center" and "direction" only symbols and as little as possible real space. On
the other hand, the paths between sense organ and brain, and between brain
and muscle, of course, must be understood in spatial sense.
^^
"Psychokym" is used to designate psychic processes conceived phj'siologi-
cally, namely, that which is conceived analogous to a form of energj-, that
something which flows through the central nen-ous sj'stem and which is at the
basis of psychic processes. "Neurokym" is used to designate the nervous proc-
esses in general.
a way that even new processes are created. The perceptions arouse
ideas which combine with the other according to definite norms (Think-
ing) and only the resultant of these processes as a whole determines
the centrifugal action.
Besides these intellectual processes, we have also observed the
effects of two other which
functions, as qualities are peculiar to
all psychic functions, or according to other views always accompany
them, namely, memory and afjectivity. In the process of percep-
tion we noticed residua of former experiences which somehow repro-
duce the latter in content and in association. And as a matter of
fact, everything psychic leaves behind permanent traces ("Engrams")
which later manifest themselves in the form of memories, routine
actions and the like, by being revived ("ekphorized") again, and
either reproduce the same experience, such as practiced movements
or hallucinations, or represent it merely in a similar manner in the
form of an image after perception.

The sight of the well aroused pleasant feelings, likewise the quench-
ing of the thirst; the idea of the possibility of infection aroused un-
pleasant ones. Thus every psychic act is "accompanied by a feeling
tone (affectivity), which is at the same time the decisive element in
decisions.
Wehave also seen that any psychic process arouses memory
images of former experiences, that through simultaneous occurrence,
these are combined in such a manner that they again are ekphorized
together and as a whole, or as a unit, that different ideas, feelings
and strivings, influence, inhibit, or enhance each other, and finally
are combined into one resultant. These different kinds of combination
among individual psychisms we call association.
a) The Centripetal Functions

Sensations. The sensations are the most elementary psychic
process which we can observe, nevertheless they are already quite com-
plicated. Every sensation of light possesses quality in two direc-
tions. There is the quality contrasted with sensations of other senses
(light, not sound), and quality within the same sensory region (color).
It further includes quantity, as the intensity of the light, the satura-
tion (mixture of the color with white) , and the local mark of direction,
as well as size and shape.

Perceptions. Perceptions arise from the fact that sensations, or
groups of sensations, ekphorize memory pictures of former groups of
sensations within us. This produces in us a complex of memories
of sensations, the elements of which, by virtue of their simultaneous
occurrence in former experiences, have a particularly fine coherence

and are differentiated from other groups of sensations.'* In percep-
tion therefore we have three processes: sensation, memory, and
association. The hitter should be taken in the sense that the sensa-
tion, as of certain color spots, or the bubbling noise, has ekphorized a
concept, like in the case of the well, and in the sense, that the in-
dividual sensory engrams, contained in the concept of the well, have
been combined with each other before and now appear simultaneously
as a unit.
The act of perception is not sharply defined. A statue may be
perceived merely as a statue, or as a Statue of Shakespeare, or as a
certain statue of Shakespeare. A word may be perceived as a word,
or as an English word, and finally as a word with its meaning
and all its relations to a definite situation. This identification
of a homogeneous group of sensations with previously acquired anal-
ogous complexes, together with all their connections, we desig-
nate as "apperception." It also embraces the narrower term of
perception.
b) Concepts and Ideas

Concepts. Let us suppose that we see ripe strawberries for the
first time, either a number of them at the same time, or several at
different times. With our sight we have sensations of certain shades
of color, certain shapes and certain proportions of size. Touch and
kinaesthetic senses give us sensations of roughness, hardness, and
weight, while the senses of taste and smell give us the taste and
odor of the fruit. Among the berries there are similarities and differ-
ences. The dissimilar sensations occur only in seeing one or a few
berries, while those that are similar appear again and again. These
are combined in the psyche into a firm complex, so that more or
less vivid memory pictures of the whole concept appear whenever a
few sensations somewhat characteristic of the strawberry are ex-
perienced. This whole structure of memories of constantly repeated
sensations produced in us by the strawberries is the concept of the
strawberry , or the "strawberry" as a genus. This can now be sup-
plemented by further experiences, for instance, by seeing that the
strawberry grows on a plant, that it is a fruit, that it has certain
botanical relationships. The process of concept formation is there-
fore similar to that of type photography.
We speak of the "concept" of an individual thing or per-
also
son, an individual strawberry, an individual person seen at different
"See below "Concepts."
times, at different distances and perspectives, and from different sides.
The residua of the repeated sensations become elaborated into a
unified picture containing only that which is common to all, and this
forms the concept of this certain thing, this certain person.

On the other hand, the concept formation can also become com-
plex, if more and more individual experiences participate in it. Be-
sides the strawberry we see many other things which grow on plants
and are capable, with suitable treatment, to produce new plants.
Ever>'thing that these things have in common again forms a some-
what firmer engram structure, that of the concept "fruit."
Concepts of activity or quality are, of course, formed in the same
manner. "To go" is composed of similarities in observing many
processes together; "blue" emphazises a certain form of visual sensa-
tions which are frequently repeated. The highest abstract concepts
are also formed in this manner without anything new in principle
being added. One person rescues his enemy, another becomes a martyr
for a good cause, and a third does not steal in spite of great tempta-
tion. All these occurrences have something in common which lies
in our feeling tone, as well as in the significance that these acts or
omissions have for the community. What they have in common, if
rendered prominent, gives us the concept of "virtue." In ourselves
and in the external world we observe that certain events always
follow upon certain others. What is common to them we call "cause"
and "effect" or in connection with the other relations of the things

and events among themselves, "causal relationship."
A very important task which must partly precede and partly ac-
company concept formation is the selection of the material. We do
not form a picture of a tree with the different perspectives of its
location and the other simultaneous experiences which were present
when we saw it, nor do we see it with all its different fronts, but
only the tree in particular in an aspect which is especially suitable
to our view. Everything else that was part of the experience in form-
ing the concept tree is eliminated in the concept-formation. The par-
ticular associations which were necessarily formed by the coincidence
of the experience, and the existence of which can be shown by
occasional tests, are inhibited. This is only a slight indication of the
enormous work our psyche must perform in putting together and sep-
arating the individual engrams, even in the simplest functions. As
a rule, only the positive process, the putting together, is noticed. The
inhibition, or the elimination, is underestimated or even entirely
ignored.^^
''See Oligophrenia.
PSYCHOLOGTCAT. INTRODUCTION 15
Simultaneously with the perception of a thing or a process we

very frequently also hear the word which designates the thing. This,
then, must also be combined with the concept in a manner similar
to its individual components, though the association is distinctly not
as close. In every person who knows the fruit, the word "straw-
berry" also evokes the concept of the strawberry. Language, how-
ever, is of still greater importance for concept formation, inasmuch
as with the help of the word it transmits to others the definitions
of concepts once formed. The individual may easily come to form
the concept "tree," but without the cooperation of former generations
it would be somewhat more difficult to form that of "plant." The
different language groups therefore have different concepts. The
French "manger''' embraces the German "essen" and "fressen." The
English "fish" is a much wider concept than the German "Fisch."
The German "Brunnen" resolves itself in French into "fontaine" and
then "puits." However, the importance of language for concept for-
mation has also been overestimated. The child was thought to be
unable to differentiate men from each other as long as it called
each one "papa," but it can be easily shown that this is usually
wrong. Likewise, the extent of a person's vocabulary was thought
to indicate the number of his concepts and consequently the con-
cepts of an English laborer of the lowest grade were supposed to
number only a few hundred. But any idiot, if he is only able to
express concepts, and any dog have many more than that. Untrained
deaf mutes form not only many concrete but also abstract concepts.
There are also people who are as rich in words as poor in concepts
(higher forms of dementia), or poor in words and rich in con-
cepts. It was also asserted that one can only think in words. The
actual facts are that in ordinary thought one uses abbreviated sym-
bols instead of concepts. Words are frequently used as such symbols,
but there are also very different kinds of symbols. Different in-
dividuals prefer different numbers some use the
ones. Thus for
word, others the figure, still others conceive them in form of a
colored spot or in regard to their mere position in a numerically
schematized scale, etc.
Concepts are not fixed; they are easily supplemented or trans-

formed by new experiences. The concept "God" is not only differ-
ent in the savage and the civilized person, but also in the child and
the adult, the educated and the uneducated. The concept of elec-
tricity is changed when one begins to study it through higher
mathematics, etc.
In every concept formation, even the simplest, we see the activity

of the process of abstraction, that is, certain classes of sensations and
memory pictures are pushed aside, and others are rendered
prominent.
Abstraction does not represent a special or even "higher" faculty,
but it is inherent in the nature of the nervous centre and hence be-
longs to psychic activity. For in both of these activities there are
no identical experiences, but only similar ones. One must, therefore,
not take too literally the statement in physiology that the same
reactions follow the "same" stimuli. In reality, the nervous centres
respond to similar processes in the same manner; unessential differ-
ences do not noticeably influence the reaction, that is, the centre or
the reaction makes use of the process of abstraction. If memory
images with associatively connected processes, such as thoughts or
actions, take the place of preformed or reflex mechanisms, then the
abstraction from these differences becomes more diversified but not
different in principle. This is already the case in perception. The
infant sees its mother at different distances, in different projec-
tions and different clothes, and yet recognizes her as the same being,
by abstracting from these differences. It is also the same kind of
abstraction as in concept formation, when in his general perception
the child raises its mother from the environment. Although the
infant never sees the mother alone, he always observes her together
with the room, yet he is able to abstract and emphasize the mother
concept. That this is an important function can be seen in those
cases where it fails. Children frequently behave very differently
toward the same persons in a different environment. In the case
of cats, one regularly observes that- they act as strangers outside of
the house to persons of their home.
That the abstraction does not merely take away from a number of
engram groups some components and combines the rest into one
sum but forms thereby a new psychic structure is self evident
and is in no way peculiar to the psyche. Thus a clock work is
as little the mere sum of its little wheels as a human being
is the sum of his cells and molecules ("mere sum" is precisely
an abstraction, which exists as little in reality as the "sum"
two).
Ideas. Everything that has been perceived by the senses, such as
qualities, things and processes, is imagined as an ekphorized memory
picture. In addition, the ideas contain also psychic structures which
have never been perceived by the senses. Among these we have all
possible combinations of sensory images, phantasies, wishes and pos-
sibilities, as well as the abstractions and their combinations with
ideas; indeed, it comprises every tiling in so far as it can become actual

in time by ekphorization and not by sense perception.^'^
c) The Associations. Thought.

Combinations of Psychisms We Call Associations.
We see tliem
in may also combine with
different forms; they
each other and cannot really be sharply separated from one another.
(1) Two synchronous functions may modify, enhance or inhibit
each other. The perception of the road as well as the obstacles
direct our steps. A moral reflection inhibits a reproachable act.
Two motives acting in the same direction promote the reaction.
Physical functions such as reflexes may be influenced in all three
directions by accidental secondary stimuli.
(2) Simultaneous or successive experiences are connected with
each other, in so far as they have a tendency to appear together in
memory, or in so far as the revival of one of these experiences recalls
the others. We may add to this the fact that our ideas and concepts,
with many or components, simultaneously appear in
all of their
memory or thought, or follow in immediate succession. If we hear
the word rose or think of a rose, we also have a more or less clear
idea of the individual psychisms red, beautiful, fragrant, all of which
form the general concept of flower.
(3) One idea generates another. We think of roses, and this
in turn suggests a verse we learned about tulips and carnations. We
set out to write our name, whereupon follow the different move-
ments accustomed and successive order. This also explains why
in the
a certain action is performed after a given signal. In the psycho-
logical selection experiment we perform the required reactions, thus
to the bell signal we react with the right hand, to the optic signal
with the left. This function already resembles much the reflex process
which is also no simple transition of the sensory stimuli to the motor
apparatus, but a setting in motion, or generating the function of a
performed mechanism.
(4) The forms mentioned may occur in any combination. In
the sense of the progressive association (Form 3), the perception of
an apple generates in the child the impulse to eat it, but also the
memory picture of the thrashing formerly provoked by stealing it,
and these later inhibit the acquisition impulse as a simultaneous

function (Form 1).
Ordinarily, however, we do not think of all these forms but only
of the following phenomena:
"For the differences between ideas and perceptions, see p. 66.
(1) Through temporal connections in experience, associations are
created in the corresponding engrams (associations are formed).
(2) These connections remain in existence with the engrams of the
experiences (engrams are associated). (3) A new event may ekphorize
the engrams of memory images which (a) have somehow become
connected at its origin or which (6) refer to the same experiences,
or which (c) In the same manner a
refer to similar experiences.
whole idea is likewise associated to a former one. In the same
manner as in simple concepts whole ideas form associations among
one another.
Association is a state so far as engrams are connected with one
another. But it is also a process, through the connection of simul-
taneous experiences, through the generation of one idea by another,
as in thought, and above all through the influence of one psychism
upon another.
Associations in the sense of permanent connections originate when
several psychisms take place simultaneously or in immediate suc-
cession, as can be seen in the act of perceiving the association of
lightning and thunder. We must assume that everything simultane-
ous and successive is connected in the psyche, not only because
such functions very frequently influence each other, but because they
appear connected in memory, as shown by every day experiments.
If something has eluded us, we can frequently recall it, by going
to the place where the thought or experience took place, indeed,
even if there is no logical connection between the place and the for-
gotten content of the ideas. And yet the associations accessible to

us evince a certain selection. Primarily we recall only experiences
which in themselves or through their connections have a certain im-

portance for us. In reference to the capacity to ekphorize there are
thus important differences in the associations, and perhaps also in
the elaboration of memory images. Unfortunately we cannot enter
here into the investigation of these differences; at any rate affective
mechanisms cooperate in them.
Moreover, as seen in every other function, there is also some-
thing negative in the formation of associations. If we have once
been accustomed to write a letter of the alphabet in a certain man-

ner, there will be a tendency always to write it the same way, even
if we did not write for a long time. But if we have later acquired
a different form of writing, then there is difficulty in reproducing
the earlier ones, even we think of it in due time. The present
if
medical training does not make psychological thinking difficult because

it ignores but mainly because it forms associations in other direc-

it,
tions and thereby virtually inhibits psychological thinking.

we consider the associations as a process of memory, we see
If
that what has been experienced simultaneously or in immediate suc-
cession is ekphorized with relative frequency. Furthermore, for evi-
dent reasons, this is also true of similar and analogous experiences.^^
The child having burned itself by a candle, is afraid of all fires.
Most associations, particularly those obtained by simultaneous-
ness, may take either the course a b or b a. In related individual
experiences, as in the details of a lawsuit, direction plays no part
whatever, as a single component associates the main concept, which
connects them all and from it other details can result in any series
of succession.
But under certain conditions direction is not a matter of indiffer-
ence. This is particularly true of associations which are important
only as they follow each other. No matter how fluently we can
recite the alphabet or a verse, to say it in reverse order can at first
be done only with difficulty. Many associations of motion we can
never reverse. For even if we are able to draw a letter, by start-
ing from the front or back, we have two different motions in which
the muscles do not simply contract in reverse order. But even as-
sociations formed by simultaneousness may obtain a one sided direc-
tion through practice. Most people who can read the printed Gothic
lettershave not necessarily the capacity to form an image of them
by hearing them. For reasons easily understood, the direction from
the special to the general has a relative preference over, and against
the reverse. A name very easily arouses the idea of the person
designated by it, while it frequently happens that the idea does not
call forth the name. The latter element is of importance in patho-

logical disturbances of memory.
Logical thinking is at first a repetition, an ekphoria of associative
connections, that were once experienced, or of similar or analogous
connections.
Every time we dig around a tree we see the roots. An association
is therefore formed between the idea of the tree and the root. If we
see and the concept root comes into consideration,
a tree it is
associated with the tree, and what is more, it has an added feel-
ing of belonging together. In the subsequent abstracted laws of
" Similar or analogous experiences have in common partial psychisms. Fur-

thermore, the sensibility of the psyche and possibly of the central ner\-ous system
for differences is limited. Whatever has differences below a certain limit appears
and acts as being identical.
logic we express it as follows: Every tree has roots; this is a tree,
therefore it has roots. But we only think in this way in exceptional
circumstances, when the correctness of the inference is questioned,
as in "proving" something. The millions of inferences, which are
daily made in thought and action, are accomplished in a much simpler
way. If one wishes to percuss a person's heart, one does not say:
Every man's heart is on the left side; this is a man, therefore his
heart is on the left side, but one simply associates the customary
place with the idea, to percuss the patient's heart.
Conclusions, therefore, like thought in general, are repetitions of
identical or analogous associations as we see them in life.
One can prove the Pythagorean proposition through four experi-

ences which every person has gone through; from two special ex-
periences (hypothetical lines drawn for this purpose) and from nine
analogous associations, wherein, however, generally existing concepts
such as triangle, right angle, parallels, and multiplication are assumed,
and hence not enumerated.
Causal thinking is only an analogy of the regular sequence of two
ordinary events, or of the general sequence of two unusual events.
When it gets warm, the snow melts. An otherwise incurable dis-
ease cured as a result of a new remedy .^^ Of course, the terms
is
"regular sequence" and "unusual event" are very indefinite. Thus,

for the savage, many things are propter hoc which for us are only
post hoc. Moreover, it must be determined through further experi-
ence, whether one event depends directly upon the other, or whether
both can be traced back to the same cause. The rotation of the earth
is the common cause of both day and night, although for children
and in myths, day arises from the night. A falling barometer and
rain have a common cause. Nevertheless we frequently see a desire
to smash the falling barometer in order to force good weather. But
causal concepts contain also inner experiences. We ourselves are very
often a link in the causal chain. Through our own actions we can
set up causes and therefore effects. We even permit our actions to
be influenced by these considerations. We see causes outside of us and
motives within us. But these two relationships can only be differ-
entiated by the viewpoint from which they are seen, and possibly
through the greater complication of the apparent motives as compared
with the apparent causes.
"Asa matter of fact no occurrence has only o?!e cause. The main difficulty
in causal investigation lies precisely in the manifold preconceptions connected
with every single occurrence. However, in psj-chological reflection it is not
necessary to solve the causal concept in the sum of conditions, as useful as it
would be in medicine to apply it \vith greater clearness than is usually the case.
Many persons have recently attached great importance to the dif-

ferentiation between "causal" and "final" thinking. There is no
difference as regards logical forms. In final thinking determinants
referring to the future are taken into consideration, as in the case
of calculating in advance an eclipse of the sun. But there is a
certain difference in the goal of thinking; the final operation deter-
mines our action, while in causal thinking the explanation obtained
satisfies our need. To be sure, the final function is the original and
usual one. The causal function acquires greater importance only in
the civilized person, who satisfies his growing need for theoretical ex-
planation and who, at the same time, has learned to value the great
advantage offered him by a causal understanding of the associations
of future achievements.
Judgment consists in a repetition of associations acquired through
experience. "Snow is white," "Kant was a great man," are expres-
sions of direct and indirect experiences. But it is important to note
that the word "judgment" signifies two things. In logic, judgment is
"the form in which cognitions are thought and expressed." we

But if
speak in psychiatry and jurisprudence of the capacity to judge, we

mean the ability to form judgments, that is, the capacity to draw
correct conclusions from the material acquired by experience.
In tracing back the individual thought processes to external as-
sociations we have, of course, not completely explained "thought."
When the concept "tree" is awakened in us, we do not always associ-
ate its roots with it. We only do this when this direction is de-
termined by a certain constellation, as in observing that the wind may
uproot the tree, or by the trend of thought, as when we think about
the nutrition of the tree. For every single idea has countless others
which are associatively connected with it. Which of these paths is
followed in a concrete case depends upon broader determinants, among
which the trend of thought and the constellation are most important.
The aim of thought is not something simple but a whole hierarchy
of a trend of ideas systematically arranged. If I wish to write now
about associations, I must constantly have this aim before me more
or less consciously, but besides this I must also view the plan as a
whole, as far as I have worked it out, the basic thought of a chapter
and of a sentence, what I have said before, etc.
Even in such mental trends which are seemingly xevy much con-
nected, themomentary and general constellation plays a noticeable
part. was momentary constellation which suggested to me the
It
example just used in illustration. The course of ideas is not only
determined by immediate, but also by former experiences. The con-
stellation also becomes an essential factor in loose or aimless think-
ing. A who is hungry, or vice versa one whose stomach is
person
overfilled, starting from any idea at all, is much more likely to hit
upon an association or an idea concerning food (dream!). A person
who is just coming from a lecture on chemistry and hears of "water"
will not easily think of water in connection with scenery or with
commercial uses.
Besides the positive effect, mental trends and constellations have
also a pronounced negative effect. Every psychic process like every
other central nervous process, not only promotes the minor selection
of like-minded functions, but it also inhibits the infinite number of
other psychisms. The development of thinking is therefore also
which must not
in this 'respect entirely parallel to that of motility,
only learn to contract the necessary muscles in proper sequence,
but must also learn not to put tension in all the others.
If we free the associations from ideas of a
as far as possible
special trend by instructing a test person to repeat as quickly as
possible the first word flashing through his mind when a word is called
out to him, we then find that the simple associations of experience
and constellation come to the surface very clearly. We thus find
associations of spatial and temporal contiguity, of similarity and con-
trast, of coordination and subordination, and of conceptual and sound
similarities. Some pretend to see in the grouping of these different
kinds of associations the "laws of association." But from what has
been said above, it is self-evident that they are only a fractional
part of the determinants of our natural thinking.
The is determined by the impulses and
principal trend of thought
the affects. We
wish to reach a definite aim. But even in the in-
dividual elements of thought we can see the influence of affective
needs. It accounts for daily disturbances and even direct falsifica-
tions of logic, which manifest themselves to a slight degree in normal
persons and to a much greater extent in the insane.^^
The material taken up forms new combinations in phantasy,
whereby different detachment from experience become
degrees of
possible. The inventor has set for himself new aims which he en-
deavors to attain by analogy to the familiar. The poet assumes
greater freedom of movement, and in fairy tales and in mythology he
is thus able to put himself in an attitude contradictory to reality,
to be sure, in a senseful manner.^"

The associations are not peculiar to the psyche alone, but they
"See affectivity; delusions.

^
Cf. Dereistic thinking, p. 45.
can be experimentally demonstrated in the other central nervous proc-

esses, in all their qualities except the quality of consciousness. It
is true that Pawiow's "association reflexes" (conditioned reflexes) go
via the cerebral cortex, which alone is capable of such plastic func-
tions to a high degree, but this does not mean that they must go via
the psyche, and particularly beyond the conscious psyche.
The mechanism of association, the possibility that parallel psy-
chisms may or may not influence each other, and that of the infinite
number of possible paths a particular one is taken by choice, can
best be understood by comparing it with the switches in an electrical

plant. These switches may connect different machines with one an-
other or let them run independently of each other; they can switch
them on or off. The constellation determined in our example by the
lecture on chemistry decreases something, which in the electrical
plant would correspond to the resistance in the direction of "chem-
istry," and it increases the resistance in other paths. That is the
reason why the idea "water" evokes associations of chemical ideas
of this concept rather than others. The comparison with electrical
switches also makes it possible for us to understand a number of
other phenomena, such as flight of ideas, schizophrenic disturbance
of association, hypnotic phenomena, the existence of different per-
sonalities in the same psyche either simultaneously or side by side,
the phenomena of the unconscious, and a number of pathological
symptoms which are either denied or reluctantly admitted. One must
be careful, however, not to connect the concept of association and
switching with any idea of cerebral localization. According to our
present day knowledge it is quite possible that the individual con-
cepts are partially (or wholly) "localized" in the same anatomical
structure.
d) The Intelligence
The foundations of intelligence lie in the process of association.

It is a complex of many functions which can be differently developed
in every individual. There is no uniform intelligence. It would
be a praiseworthy task to elucidate once for all the whole concept of
intelligence. Besides the faculty of intelligence, it would be im-
portant to abstract correctly the following points: (1) the capacity
to understand what is perceived or explained by others, (2) the ca-
pacity to be able to act in such a manner as to achieve what one
is striving for, and (3) the capacity to make correct combinations
of new material (logical power and phantasy).
All these achievements are primarily dependent upon the numher
of possible associations. The greater the number of stones at our
disposal, the greater the number of ideas and the finer theshades
that we can express in the mosaic of our thinking. In the animal
series, or from the idiot to the genius, the scale of intelligence de-
pends principally upon an increase in the possibilities of association.
Of secondary importance we consider the speed and ease in the flow
of associations. For the scholar in his study it may not be very
important how much time he takes for his reflections. But a per-
son in active life must be able to survey a situation rapidly and
to draw the conclusions necessary for action. Intelligent achievement
also includes the proper selection of the material to be associated. I
only enumerate this in the third place because this function is com-
paratively satisfactory to the average person. It is relatively rare
to find many irrelevant associations; one observes this mostly in
oligophrenics lacking mental clearness whom we shall discuss later.
To select the appropriate material it is necessary to differentiate
between the important and the unimportant. This is a complicated
function and depends on the survey of the whole subject and there-
fore, in the final analysis, again on the number of associations. In
order to make new combinations and not merely to follow in the old
grooves, there must be a certain capacity to split up the associa-
tions into their components,^^ but one also needs a special activity
of the will and thought in the direction of controlling the circumstances.
The more use is made of elaborated
greater the intelligence, the
thought material. The intelligent person makes far less use of con-
cepts which are still closely related to perceptions than of inferences
drawn from them, and often enough he is altogether unable to
reproduce the original experiences. He follows his judgment of a
person without thinking how he came to this judgment. He also
thinks his concepts with their relationships. On the other hand,
he also resorts to short cuts; this is partly accomplished through
the arrangement of details into a uniform main concept which is
already a short cut, and partly by changing complex ideas into
symbols, which are not only used in intercourse with others but
also in thinking (e.g. mathematical signs like tt, sin, etc.).
A schoolgirl asks her mother for some money for a poor friend,
so that the latter may join in a school picnic. The mother refuses,
since she has no money herself. The girl observes that her playmate
frequently earns a few nickels for running errands. She now conveys
to her the idea that all she has to do, in order to get enough money
for the picnic, is to save this money instead of spending it, and for
" Cf. Concept formation, p. 14, and the oligophrenias.
this purpose she gives her a small, improvised, savings bank. Besides
she keeps on inquiring how much money the child has earned and
what she has done with This proved to be quite successful.
it.
Here we deal, in the place, with a characterological function

first
on which all that follows is dependent. The girl was not satisfied
with her mother's answer and tried to find another solution. But
pure intelligence also had a share in this first step. The girl had
to recognize the possibility of providing help, before she found the
solution, while a feeble-minded person would have faced an impos-
sibility from the very beginning. The next step was seemingly very
simple, but only seemingly, for often enough it fails in reality, in
spite of the fact that it is so frequently drilled in; we refer to the
application of the thought that twenty nickels make a dollar, that
is, that one has to save only twenty nickels in order to have a dollar.
To seek a way out of a difficulty, in spite of the fact that the nearest
solution is impossible and the application of this mathematical prin-
ciple i what from those that remain
differentiates civilized people
primitive. After giving the advice to save, many
a sage would have
considered the matter settled. But here we have besides, the im-
portant idea of the small savings bank. This required the "feeling"
which many moralists lack, and which is of course, a purely in-
tellectual process, that mere advice was not sufficient, that is, it
requires a complex of associations regarding the fickleness of her
friend and the desire to make it harmless. For this purpose a means
was invented, with the help of imagination, to interest the spend-
thrift in another direction. That this solution was sought and found,
of course again presupposes the possession of a great number of ideas
regarding the psychology of her friend, and, in the long run, of people
in general. Furthermore, there was the capacity to utilize all these
ideas at the proper moment, and at the same time to sift the experi-
ences into what is important and w4iat is unimportant for this par-
ticular case. This latter selection requires among other things the
constant presence of the psychological ideas about the motives of
action, for it is with the guidance of these ideas that the sifting must
be done. Intellectual as welli as characterological functions are
involved in the subsequent supervision of saving and in the dctach-
ment from the usual associations. The latter is particularly im-
portant when it is not merely a question of understanding, but
of acting, or finding new solutions. The usual thing is the idea of
obtaining money from parents; if this is impossible thousands of
young girls will resign themselves to what is apparently unavoid-
able. Our heroine detached the thought of procuring money from the
idea of the usual source and sought a different one. The classical wit-
ticism of the egg of Columbus is a very striking example for the
significance of this detachment. Columbus could count on the fact
that his narrow-minded rivals would not be able to detach them-
selves from the stereotyped ideas of the undamaged egg. If it were
not for the strong resistance of ordinary minds against the unaccus-
tomed, as represented by the broken end, the solution would instinc-
tively have had to force itself upon them. One need merely call to
mind an egg of wax.
Afundamentally different grading of intelligence is that according
to clearness of ideas. This does not depend on the number of pos-
sible associations; on the contrary, in those who lack clearness one
often gets the impression that there are too many associations, or
that not enough are inhibited. On the other hand, there is not
much that is unclear in those concepts which are formed by the
ordinary oligophrenics themselves. Idiots do not go very far beyond
the material existence in forming concepts and that alone relatively
protects them against a want of clearness. Lack of clearness will
appear at most if concepts are forced upon them from the out-
side, for the understanding of which they are too feeble. On the
other hand, there are intelligent and even highly gifted people
who utilize many confused concepts. Under some circumstances this
may have a certain advantage for discoverers: they can deduce a
hypothetical concept from any experience without great difiiculty and
if it does not properly conform to subsequent experiences, they can
without noticeable effort, or even without knowing it, transform it

in accordance with the new conditions, that is, they can use it in a
somewhat different sense. It is self-evident that this quality is very
dangerous and can only be rendered harmless by very great intel-
ligence. What we mean here by confused concepts can be best ex-
plained by using the illustration of the constellations. The astronomer
knows every star belonging to Orion; to him that is a very sharply
defined concept. The layman, however, knows only a few stars of
it or only the celestial region where it is located. But he is con-
scious of his weakness. He has an incomplete but not a confused
concept of Conscious of his ignorance he will not make the mis-
it.
take of suddenly taking an entirely different group of stars for

Orion and will not say that a comet has just entered Orion, when
in reality it does not touch Orion at all or is just leaving it. But
the unclear person may express himself in this manner, because there
are no definite and constant limits to his concepts; he speaks of
Oriqn when it is simply a question of that legend; at times he will
add to it which at another time he does not include; what the

stars
unclear person lacks particularly is the conscious and vivid dis-
tinction of related concepts. He who calls all psycho-motor diffi-
culties inhibitions may have a clear concept of them, even if it is
unsuitable for our diagnosis. But a person who speaks of inhibition
and blocking and two terms,
does not see the difference between these
that are now current in psychiatry, has an unclear conception of
them.
There are people whose more complex concepts are all unclear in
this manner. Many conceal this defect by a clever way of ex-
pression, but in life they fail like all the other feeble-minded.
Intelligence in any sense whatsoever is never a unit. There is
no one who is eminent in all psychic fields, while most idiots naturally
fail in all directions. Practical intelligence does not necessarily imply
theoretical intelligence and vice versa. The great difference between
school intelligence and worldly intelligence depends only partly on
the fact that pedagogues with their one-sided standards are de-
ceiving themselves regarding the abilities of their pupils.-^ A num-
ber of highly gifted people were poor in school. Alexander von Hum-
boldt, for instance, "was unfit for study" according to the judgment
of his teachers. And even after the school period "worldly wisdom"
is something quite different from intelligence in general. The particu-
lar gifts for mathematics, languages, engineering, psychology, philo-
sophical thinking, etc., are well known. This specialization may go
to very great lengths. Indeed there are people with one-sided genius
for figuring out on what day of the week a certain date will come,
or for playing chess, etc.
Evenin such cases we do not merely deal with abstract intel-
ligence. The good mathematician not only has the ability to think
mathematically but also the im-puhe to occupy himself with it. But
the intellectual effects depend also in other ways on their inter-
play with other functions, principally the ajfects. We have seen in
the case of the schoolgirl how the impulse to think and act co-
operated in controlling the circumstances. A people without a thirst
for knowledge, like most of the Orientals, even though it had the
greatest intelligence and perhaps a vivid phantasy, would nevertheless
be unable to accomplish anything in the sense of our occidental
technique. The abulic schizophrenic and the over-labile organic de-
ment both appear demented as a result of their affective disturbances.
"Unfortunately one still observes quite frequently that the result of educa-
tion and school training, the mere acquisition by memorj' of the subject matter
of education, is mistaken for intellectual accomplishments.
Mere clearness of thinking, likewise, is considerably improved if one
has the patience and the impulse to think a matter through. Logic
falsified by affects is constantly seen in the insane. A failure of
the intellectual functions may be due to a disturbance of the equilib-
rium between reflective power and affectivity (apathy on the one
hand, and proportionate dementia on the other). Important above
all, is the influence of the feelings relating to the ego which only too
readily cause an entirely different standard to be applied to one's

own than to other things. Furthermore, a large part of
interests
worldly prudence is due to perseverance. The ability to concentrate
the attention in understanding and elaborating things may have an
important influence upon intelligence. The ability to find new ma-
favored by a certain degree of phantasy or is perhaps identical
terial is
with it, if by "new" we do not merely mean the correct "new"
material. That a good memory considerably aids intelligence, that it
may even replace intelligence and conceal the weakness of it, is self-
evident. For, the more intelligent a person is, the less need he has
for primary memory, which reproduces experiences exactly as they
have been experienced. For the intelligent person uses deduced con-
cepts; a "fish" does not call to his mind a collection of all the
fishes he has ever seen, but he has for it a very abbreviated formula
which is of a zoological-scientific content.
e) Memoey
Everything that has been psychically experienced leaves behind a
lasting trace, or engram^. We recognize this by the facts, that the
more often a process has been repeated (practice) the easier it runs
off, that past experiences act in a modifying way on some actual
processes, that repeated experiences are recognized as repetitions, and
above all that one remembers psychic processes. What modification
the engram represents we do not know. In remembering something
there must be a recurrence of a function resembling a previous ex-
perience, like an idea of something perceived, or of a function almost
like it, like the repetition of a practiced motion. We designate this
as an ekphoria of the engrams. That every experience, including
unconscious ones, really leaves behind engrams, cannot be directly
demonstrated, but seems very probable from off hand tests, fur-
it
nished us by chance memories. In dreams, hypnosis, and in diseases,

and sometimes also in the normal states, experiences are recalled
which would otherwise be considered as impossible of recollection,
A young woman who could neither read nor write reproduced in
a feverish state Latin, Greek and Hebrew verses, of which she knew
nothing in her normal state. During her childhood she lived with a
clergyman, who was in the habit of reciting such sayings.'''^ A person
hypnotized drug store may, under certain conditions, reproduce a
in a
great many of the inscriptions on the glass jars, even if he under-
stands nothing about them.
Although every experience leaves an engram, those memories which
we usually utilize are really products of very complicated elaborations.
We do not form an image of a momentary vision of a certain region
by confining it within the limits of the field of vision at that par-
ticular time, but we image a tree, a meadow, a meadow with trees,
mountains, etc. In short, in the available engrams, the experiences
are analyzed and synthesized according to the rules of concept
formation.
The ability to form engrams, the engraphia, was designated by

Wernicke as "impressibility" (Merkfdhigkeit) and this has been
hazily contrasted with "memory." Memory in this connection no
longer means the whole memory, a designation for which is clumsily
lacking, but the retention of the ability to ekphorize the engrams.
It is still unknown in what respect the latter may be regarded as a
special quality. The only thing definite is that under certain condi-
tions many engrams cannot be ekphorized, and that, if a cause for
it found at all, it has so far always been in something entirely
is
different from the nature of the engrams; it was mostly in affective

obstacles. So far then the mere inability to remember has thus far
not shown us why the engrams are lost. A more detailed discussion
will be given in the chapter on pathology of memory.
The engrams seem to last as long as the brain is not verj' ex-
tensively and markedly injured. It is not very rare that apparently
long lost memories from childhood reappear in old age with great
vividness. All things being equal, the older an engram the greater is
its resistive capacity to ekphorization. Forgetting therefore is not as

a rule due to a disappearance of the engrams, but to an inability to
revive them as memories or to ekphorize them by association.
The apparent paling of those pictures of perception which are
tangibly vivid is really only a substitution of the same by elabora-
tions which are more suitable for the idea and hence more capable
of recollection. Another way of weakening by age the capacity to
recall an engram was shown by Ranschburg.-* Material learned by
heart consisting of similar components is more difficult to reproduce
^Carpenter, Mental Physiology, p. 437, Tnibner, 1896, London.

**
Ranschburg, Ueber Wechselbeziehungen gleichzeitiger Reize usw. Zeitschrift
fiir Psychologie 67, 1913.
than that which is altogether dissimilar. In self-observation we find
that to a large extent memories disappear in a manner that one is
at first uncertain which of several similar memory pictures is the
correct one, and that gradually so many possibilities offer themselves
that one no longer able to choose, or that one is altogether unable
is
to grasp the correct engram out of the great number of others. Other
disturbances and falsifications of memory are determined by the
affect.
There are facts, however, which could, in the first place, be ex-
plained by a change in the engrams. Thus, rooms which we saw
in childhood much smaller in later life than we had
often seem
expected. We
have enlarged the image with the growth of the size
of our body. Whoever studies the testimony of witnesses in court
proceedings will be surprised how, even in very simple matters, people
will make the most contradictory statements in good faith; this
naturally occurs most frequently in the case of precipitated or excited
events. But even without any particular reason the errors are often
very great. The experiments regarding the giving of evidence, par-
ticularly made by Stern's school,^^ have furnished us much
those
unexpected information concerning this. Every one who observes him-
self, even if only a little, is familiar with the daily irregular falsifica-
tions which reproduce a memory not only incompletely but change
it also in other ways. Thus the memory image of a somewhat un-
familiar person, garden, or of an event is frequently quite different
from the reality of it, and in time also loses regularly in correctness
and in clearness.
In all such cases, however, the original correct engram con-
tinues to exist together with the modified one. For the error is often
subsequently corrected, either through reflection or through the fact
that the correct memory involuntarily appears on some occasion. In
pathological conditions we can frequently demonstrate that the cor-
rect and the falsified idea exist at the same time.
Such occurrences prove that in falsifications of memory we do not
deal with alternations of the engrams, but with a complex process
which is analogous to the creation of new ideas. How much of this
has taken place in the unconscious during the apparent latency of
the engrams and how much during the act of recalling is unknown.
Even in a sober-minded normal person the falsifications which cor-
respond to an affect, namely, to the wishes of the individual, are very
marked. It is very instructive to reread one's diary after the lapse
of a number of years. One finds a great deal which he no longer
''Stem, Beitrage zur Psychologie der Aussage. Barth. Leipzig, 1903.
believes even though it is written in his own handwriting. But on

closer examination one finds that the version of the diary fits least
the person concerned.
Ekphorization of engrams can be either conscious or unconscious.
Unconscious memories of ideas can only be demonstrated in a round-
about way, but well-grounded capacities, particularly of the motor
type, very easily take place unconsciously. If we were once able to
swim, we make the correct swimming motions as soon as we get into
deep water.
The ekphorias that are most frequently spoken of are the con-
scious memories. Without exception they are probably generated by
way of associations. The laws of memory are therefore the laws
of association. The better drilled an association, the more associa-
tive paths lead to an engram, the easier it is to remember. It is
therefore relatively easy to remember what has been brought into
many relationships, or what has been understood. An unintelligible
chaos, as for instance a story heard in a foreign language, cannot be
reproduced. Likewise it is just as impossible, in the ordinary con-
scious course of thought, to revive all those innumerable engrams
which we take up unconsciously as all the faces of the unfamiliar
people we meet on a walk.
The faculty of memory very easily disturbed through such a
is
constellation as recalling something otherwise familiar in a new

relationship; we are often unable to do so. The affects, however, as
we shall see, are particularly important as factors inhibiting and
facilitating memory. Pleasurable experiences are particularly eas}"
to remember. In unpleasant experiences there is a struggle between
two antagonistic tendencies; on the one side we have the one belong-
ing to the affect in general, which makes the memories more vivid,
and on the other side there is the tendency which strives to shut out
everything unpleasant, hence also a disagreeable memory. L^npleas-
ant events are frequently crowded out of memory, especially if they
somehow depreciate the personality. Thus the lapse of many decades
creates the idea of "the good old times." Most important of all, how-
ever, are the actual affects, which cause only those memories to come
to the surface which are suitable for them.
Recognition is a special form of memory. If we hear or see some-
thing for the second or third time we regularly recognize it as a
former experience. One speaks of a "quality of familiarity" in the
repeated sensation, but one is unable to describeit. It is more im-
portant to know that recognition is than spontaneous recol-
easier
lection. Thus, even if one is absolutely unable to remember the
oriental name of Alexander, one will easily recognize it, if among other
names Iskander is mentioned. Not every one is able to form a clear

image of a person, but is able to recognize him as soon as he sees
him.
f) Orientation
Present and former perceptions combine into orientation as to time
and place, so that one always thinks more or less conspicuously of
being at a certain place and at a certain period of time, and con-
nects his memories with these dates. It is self-evident that orientation
depends on memory (for it is impossible when memory is lacking),
on perceptions (for hallucinations can produce an entirely different
place), and on attention (for if we are absorbed in thought or in con-
versation while walking or riding in a vehicle, we may suddenly find
ourselves at a different place than we had expected). But as pathology
shows, there is besides this also an independent function of orientation,
the disturbances of which are not necessarily proportional to the dis-
turbances of other functions.^*' Nevertheless we find no anomalies
of orientation without a disturbance of other functions.
Orientation as to space, which is constantly controlled by the
eyes, is of course much surer than orientation as to time, which
requires an uninterrupted memory record and has only a linear
dimension.
Something entirely different is the orientation as to situation, which
tells us why we are at a certain place, what relationship we have
to the other people, etc. This is of course a function of reflection, as
far as it depends on the understanding of complex conditions.^^
g) Affectivity
Every psychism can be divided into two sides, an intellectual and

an affective. The remains unnoticed, but is never al-
latter often
together lacking, as can be demonstrated through comparisons. For
instance, most people can immediately answer the question whether
they like better a trapezoid or a square. It can be concluded that
the mere sight of such simple figures is associated with a feeling of
pleasure or displeasure.
Under the term affectivity we comprise the affects, the emotions,
and the feelings of pleasure and displeasure. The expression "feel-
^ E.g., following an alcoholic delirium, orientation as to time and place some-
times remains disturbed a few days longer, while the other functions appear
quite normal.
" Regarding Wernicke's classification of orientation into autopsychic somato-
psychic and allopsychic, see the disturbances of orientation, p. 110.
:
ing," which is frequently used for this wiiole group of phenomena, is
misleading. For it is also used to designate sensations in the lower

sensory qualities, such as feelings of warmth, somatic feelings, and
Munk's sphere of feeling, as well as indefinite perceptions such as
the feeling of someone approaching. It is furthermore used to des-
ignate the result of inferences originating in the unconscious, such
as reaching a diagnosis by a "diagnostic feeling," and finally it is
used to designate complex processes of cognition, the elements of

which are not clear to us, such as the feeling of familiarity. The terms
"affects" and "emotions" are too limited in their application, and they
really do not embrace the simple feelings of pleasure and displeasure.
Affectivity includes somatic as well as psychic manifestations,
which are sometimes conceived as symptoms and sometimes as effects
of the same.
It influences gestures in the broadest sense; this includes the
emphasis in speech, the attitude of the body and muscular tone; it
also influences the vascular system, as in blushing, turning pale, and
in palpitation of the heart; and it also affects all secretions, such
as tears, saliva, urine and faeces; finally it influences also the whole
trophic system of the body.
On the other hand^ affectivity is markedly dependent on physical
influences. We note this in anxiety of endocarditis, in depressive
irritability of dyspeptics, in the euphoria of tubercular patients or
alcoholics, and in the affective manifestations of inner secretions.
In the psychic field we must first mention the undescribable subjec-
tive sensations of pleasure, displeasure, joy, sadness, anger, and similar
feelings.
Affectivity also determines our actions. We strive to procure and
retain pleasure, that is, pleasurably accentuated experiences, and we
keep away from displeasure. If we take upon ourselves displeasure, it
is only to avert a still greater one or in order to obtain some pleasure

which we value higher than the assumed displeasure.
Affectivity has a determining effect upon action also by way of
thought which is more influenced by it than is ordinarily imagined. In
regard to its content this is shown in two ways
(1) The path is cleared for associations corresponding to an actual
affect, i.e. these associations are favored, while all the others, particu-
larly those incompatible with the affect, are hindered (the dominating
force of the affects). From this one may conclude: (a) There is a
compulsion to occupy oneself with the emotionally accentuated subject.
(Actual emotionally accentuated experiences can only be ignored in ex-
ceptional cases, and under certain conditions they absolutely prevent
,
any thought (b) Logic becomes falsified.
in other directions.) (In a
state of euphoria, a person unable to take into account all the poor
is
chances; they do not even "occur to him," or they are deliberately dis-
regarded in the logical operation. One ignores his own faults.)
(2) The valuation, or the logical weight of the ideas which are in
accord with an affect, become enhanced, whereas the value of irrelevant
and especially of opposing ideas is depreciated. From this again one
may infer on the one hand, that there is a tendency to occupy oneself
with those ideas which seem important, and on the other hand, that
there is a broader alteration in the logical operations. A timid person
puts too high a value on the dangers involved and too low a value on
the good chances, if he considers them at all. An investigator whose
ambition depends on one of his formulated theories will continually
it, and he is unable to give full weight to the
find corroborations for
arguments against it.
The effects of an affect manifest themselves differently and have a
different significance, particularly in psychopathology, depending on
whether they are caused by a general mood, such as euphoria, sadness,
anxiety, etc., or whether they only emanate from a single affective idea.
On the whole, one can be in a different mood and yet have a complex
of ideas, which, whether it is conscious or unconscious at the moment,
is endowed with anxiety or joy or chagrin. In the latter case not all
associations are influenced in the sense of this affect, which controls
the idea, but only those which in any way touch the "complexes." ^
Our thinking may be quite correct in all other respects, but it is very
one-sided in regard to some one who has angered us, or some one with
whom we are in love. As a rule, all complexes have a tendency to estab-
lish a relationship between themselves and the other experiences (The
onanist imagines that every one is looking at him because of his vice)
and thus lead to the formation of false self references in both normal
and pathological people. If the thought is difficult to bear, the whole
complex can more or less be split off from consciousness and merge
into the unconscious but it does not always lose its influence upon the
psyche as a result. The effects of an affectively accentuated complex
are designated as katathymic by Hans. W. Maier.
The influence of affectivity upon thought and action becomes re-
enforced by its tendency to spread. In point of time the affects quite
generally outlast the intellectual process at their basis, and what is
more, they frequently continue for a long time. Besides, they easily
"irradiate" to other psychic experiences which are associated in some
way with the idea having an affective tone. Thus we love the place
"^See the following page.
where we have experienced something beautiful and we hate tlie inno-

cent bearer of bad news. Love often is "transferred" from Uie origi-
nally beloved person to another who bears some analogy to the former
or it may be transferred to an object, such as a letter, etc. Even in
normal conditions it may happen that the transferred affect detaches
itself from the original idea, so that the latter seems indifferent, while
the secondary idea carries the affect which does not properly belong
to it {Displacement of the affect).
If a definite affect persists and dominates for some time the whole
personality with all its experiences, we speak of a mood. The tendency
of an affect, which has once appeared, to continue and to become trans-
ferred to other experiences, as well as its influence upon thought, facili-
tate the occurrence of permanent moods. But the latter maj' also be
the result of physical causes, based on constitutionally determined
moods or as partial symptoms of temperaments, alcoholic euphoria,
mania, melancholia and similar states.
Positive or pleasurably accentuated affects accelerate the train of
thought, while negative ones retard it. As a result of acceleration,
thought sometimes becomes changed even in content, it becomes more
superficial; -in a high degree of retardation it never reaches its object.
The affects possess great associative power. An unpleasant affect
has a tendency to ekphorize former affects of a similar nature. Thus
an event, not very important in itself, may produce a great effect by
reviving affects from former situations of similar quality of much
greater emotional tone. It is remarkable that the former events often
remain unconscious in this process. In other cases the very experiences
are recalled to memory and then reenforce and modify
in the first place,
secondarily the original affect. These peculiarities are of great signifi-
cance in the pathology of the neuroses.
By which do not belong to them the affects
inhibiting the ideas
also exert a limiting influence upon the complexes of ideas accentuated
by them. In some connections such complexes form a whole category
and between them and the other psyche there exists not only an associ-
ation readiness for ideas that can be utilized compatibly, but there is
also a certain association-hostility to anything not belonging to them.
They are therefore only slightly influenced by new experiences and are
not easily accessible to criticism. If the affective tone is unpleasant,
they are even readily repressed into the unconscious.
If such bundles of ideas, which are held together by an affect, exert
a permanent influence upon the psyche, we call them briefly ''com-
plexes."
A complex may thus be formed in regard to a person who has dis-
appointed us, so that everything connected with him is not only bur-
dened with the unpleasant feelings, but it also participates in the
association readiness or in the repression which adheres to the idea of

this person. The memory of the place where he lives produces an
irritable mood and reaction; distant ideas which would ordinarily never
be associated with the person call him to mind, or, the opposite occurs,
the whole complex is forgotten, repressed, so that we find it difficult
to recall even the names of his friends. The complexes are mostly
either vividly conscious, or later repressed and unconscious. In both
cases they influence our thinking, striving and mimicry. The most
common complexes and many are recog-
are connected with the instincts
nized in the attitudeand in the whole behavior of the individual. Feel-
ings of inferiority in any sphere (insufficiency complex) which con-
tribute to the formation of many neuroses are very important and
especially those with an ambivalent feeling tone.^^ Such complexes
may even acquire a kind of independence as far as certain voices may
represent a "greatness" that the patient would like to attain and
others may personify a weakness, which hinders him in the success of
his plans.^
An intellectual process, a perception, an action in response to a
stimulus, and a thought, are all in a certain respect partial functions.

We could imagine that only a part of the psychic organism participates
in these processes. In contradistinction to thi^, the affective processes
signify an assumed attitude of the whole person. They participate in
the affective changes of all psychic activity, in the creation of uniform
striving for an aim on the part of all associations, in a general facili-
tation or restraint of the psychic processes, in the changing of the blood
supply in the brain, and in similar mechanisms. Intellectual and affec-
tive processes are related parallel manifestations; they represent the
local side of the same psychism.
and the general Nevertheless, they
can subsequently separate so that each process may proceed indepen-
dently or become associated with other processes of the other series. As
a result of irradiation an affect may become connected with ideas to
which it was not originally related, and still remain in contact with
the original idea, but it may also be completely separated from it.
Under certain conditions we may form a distinct image of the death
of a beloved person, either while the event actually takes place or later
from memory, without experiencing with it the corresponding affect.
On the other hand, the idea of mourning may be attached to a secondary
" See p. 125.
Cf. The classical self-portrayal of Siaudenmaier, Die Magie als experimen-
telle Naturwissenschaft, Leipzig, Akademische Verlagsgesellschaft, m. b. H. 1912.
idea indifferent in itself, as to the perception of the place where we

last saw the deceased or to a song. In such a case we are frequently
unable to understand the significance of the affect (displacement). Or
the affect may become detached from the idea it belongs to without
associating itself with any other idea. There is, for example, "a freely
floating anxiety" vv^hich originally belonged to a fearful idea and was
repressed into the unconscious; one feels anxiety but docs not know
why. There is, however, an anxiety which cannot be differentiated
from this one, which may be of physical origin, as in circulatory
disturbances or in melancholia. In both cases it may attach itself under
certain conditions to some secondary idea, which in itself need not at
all be endowed with anxiety.
The show more clearly than anything else how the psyche as
affects
a whole always the decisive factor, and how the individual ideas,
is
concepts, and affects which we emphasize are only artificial classifica-

tions. The taste of a certain food may be very pleasant to one hungry
and very unpleasant to one who has over-eaten. Music, which in itself
would be considered pleasant, may be very disagreeable if it is not in
harmony with the mood of the listener, or if he is disturbed by it, or
if he happens to have very sensitive nerves, or if he is in a state of
melancholy. If a lunatic gives us a box on the ear it produces no affect

in us, but under different circumstances it may fill us with the greatest
anger or despair. Careful observation impels us to make the general
statement, that in reality we never react to a single experience or idea
with a definite affect, but that the affect is always merely a part of the
whole complex of functions which forms the actual psyche.
In human beings endowed with memory who do not merely live for
the moment, but form ideas from the past and have ambitions for the
future, the tendency to manifest themselves on the part of the ideas
and strivings, carrying a negative affect, conflicts with the opposite
tendency to keep away from the unpleasant. Thus if one has a feeling
of revenge or sexual love for one's mother, which is intolerable to a
moral person, he usually solves this conflict by shutting the idea out
of consciousness in statu nascendi. Notwithstanding this, the idea con-
tinues to exist and may influence his actions in a roundabout way, or it
may provoke symptoms. The idea has simply been repressed into the
unconscious. Repression naturally plays a great part, in psycho-
pathology.
Every affect has a tendency to act in a definite direction. Because
some one has insulted me an apparatus (chance apparatus) results in
my psyche which seeks to avenge me, just as the accommodation in
the psychological experiment creates a kind of transient reflex ap-
paratus, which, without any further exertion on the part of my will,
responds to the appearance of a red light with a pressure of the right
forefinger on the button, or like any resolution when formed incites
one to put it into execution. The apparatus is shut off, e.g., through the
fact that it has accomplished its purpose. I have revenged myself, or
the experiment is finished, or it stops because it has lost its purpose,
as when become reconciled with the person who offended me. Accord-
I
ing to the strength of the affect it has a motive power which can be
compared with physical tension of energy. If the motive power is too
weak, or if the function of the apparatus is restrained by external cir-
cumstances of inner opposing forces, then the apparatus with its
"tension," remains inactive. But if new impulses are added to the

same or even to a similar action, the "tension of the apparatus then
becomes reenforced, so that, under certain conditions, it finally over-
comes all obstacles in an explosive manner and like an inhibited reflex
it may even shoot extensively and intensively beyond the aim. One
then conceives the impression of an "accumulation of affects." Quali-
tative departure from the original purpose, in the form of simple
mimetic expressions, such as exultation, screaming, or smashing of an
innocent object, may also occur and they suffice to put the apparatus
out of action. One then speaks of a discharge or abreaction of the
affective tension, while the real process consists in the dismantling of
the apparatus in question.
For, if the apparatus is not actually put out of function, it remains
throughout life and may cause in normal people some sort of an incom-
prehensible readiness to react explosively to certain experiences; in
sick people it may provoke a variety of symptoms without losing any
energy thereby. is particularly true if the affective complex has
This
been repressed. In that case it cannot be shut off by the conscious
personality and may continue unrestricted in the same condition; in-
deed, through similar new experiences the complex may even acquire
more and more tension. Exaggerated sensitiveness to fear in an adult
may thus be traced back to a repressed terrifying experience of child-
hood which has been furnished with tension from all similar later ex-
periences, without any knowledge of it on the part of the patient.
Indeed, such an occurrence may produce the tendency to experience
similar things over and over again.
Chance apparatus occur also without any special affects, wherever
there an intention to do something, even if it is simply a question
is
of finishing some thought. Secondary experiences and thoughts of the

previous day to which one often pays no attention and which appear
in dreams also belong here. Habit too creates chance mechanism which
are particularly difficult to abolish, because they are not set for a
definite aim happening but once and the attainment of which auto-
matically stops the machine.
Affectivity varies greatly in different individuals and frequently
even in the same person at different ages. While every normal person
must call a cat a cat and observe the general rules of logic in order
to get along with his fellow-men and the external world in general, he
may love the cat or consider it a monstrous animal. The individual's
mode which primarily expresses itself in affectivity, is not
of reaction,
tied to such narrow standards as logic. It is for this reason that one
may argue, for example, whether or not the isolated absence of feeling
tone in moral concepts is to be looked upon as pathological.
The character of a person is almost exclusively determined by
affectivity: Animated and easily changeable feelings constitute the
sanguine temperament, while persistent and profound feelings the phleg-
matic character; a person who does not accentuate the concepts of good
and evil with pleasure or displeasure, or who puts a weaker accent on
them than on egotistical ideas "has a bad character." Next to the
quality of reactions we must also consider the rapidity and force of the
affects and hence of the impulses. Jealousy, envy, vanity are charac-
teristics as well as affects. Affectivity is also responsible for laziness,
energy, steadiness, diligence and carelessness.
From what has been said above, the function of affectivity in our
psyche is It determines the direction and force of action, and
evident.
through its endurance and irradiation, as well as through its influence
upon the logical functions, it provides uniformity and emphasis for
this action. It especially regulates social intercourse with our fellow-

men. Here it is important to note that we constantly apprehend and
respond instinctively to the most delicate fluctuations of affects in our
fellow-men.
We strive for the pleasurable, which on the whole consists of what
is useful to the individual or the genus. The reverse is true of the dis-
pleasurable. Exceptions to this are concerned with experiences which
are quite rare and therefore do not endanger the existence of the genus,
or with occurrences to which the race has not yet adapted itself because
of lack of time. Thus we find the taste of the beneficial cod liver oil
disagreeable, but that of harmful alcohol pleasant.
That excessive affects may be harmful (paralyzed with fear, blind
rage) is quite obvious. Compared with the daily and hourly oc-
currences in which, for example, a very slight anger or slight fear is a
help in overcoming an obstacle, they are rare exceptions which cannot
threaten the existence of the genus.
Physical pain assumes a special position. It accompanies destruc-
tive processes in the body and is localized like a physical sensation.
At the same time it is also a feeling or an affect and has the same
significance. It forces us to direct our attention to injuries of the body
and to ward them off energetically. There are also other "primitive
feelings" (v. Monakow) which cannot be
, clearly separated from our
conception, as for instance hunger.
h) Attention
Attention is a manifestation of affectivity. It consists in the fact
that certain sensory perceptions and ideas which have aroused our
interest are facilitated and all others inhibited. If we are performing
an important experiment, we only observe what is relevant to it; every-
thing else is entirely lost to our senses.
If we wish to concentrate on a certain theme we call to our assist-
ance all appropriate associations and exclude the others. The greater
"clearness" of observation and thoughts to which we direct attention
is merely the expression of the fact that everything relevant is ob-
served and considered while the irrelevant is eliminated. Hence in
attention the "interest" inhibits and facilitates the associations in the
same way as is ordinarily done by the affects. The more successfully
this is done, the greater is the intensity or the concentration, and the
greater the number of useful associations put in operation, the greater
the extent of attention.
A distinction is also made between tenacity and vigility of attention
which are usually, but not always antagonistic to each other. Tenacity
is the ability to keep one's attention fixed on a certain subject con-
tinuously, and vigility the capacity to direct one's attention to a new

object, particularly to an external stimulus.
We must also differentiate between maximum and habitual atten-
tion. Many patients habitually observe very little, they do not orien-
tate themselves when they go to an unfamiliar place, etc. But if they
are induced to exert their maximum of attention, they can do this
without any difficulties and sometimes particularly well.
If attention is directed by the will, we designate it as active: if by
external occurrences, we call it passive. Maximum attention will
always be active while habitual attention may be either active or pas-
sive. The latter plays a special part in recording the daily happenings
of one's environment.
The success of attention is, of course, not merely dependent on the
affect,but also on the general disposition of the psyche. Some people
are not capable of great concentration although they seem to possess
a sufficiently strong and stable affect. Exhaustion, alcoholic effects,

and many pathological states hinder concentration and tenacity. The
extent of attention is, of course, also dependent on the general capacity
to form associations, and it is therefore not as great in people of lesser
intelligence.
The opposite of attention is distraction, which shows two contrasting
forms. On the one hand, if a pupil shows a lack of tenacity in hyper-
vigilityhe may be designated as distracted if he is disturbed by every
noise, whereas hypertenacity and hypovigility are characteristics of
the absent-minded scholar. A third form, which is pathological in its
more pronounced manifestations, is due to an insufficient capacity to
concentrate. The latter may have an affective basis, as in the case
of neurasthenia, or it may be due to disturbances in association, as in
schizophrenia and certain deliria, or it may depend on more complicated
conditions, such as exhaustion.
Temporary distraction usually originates in a definite situation. It
is self-evident that an affect will hinder the attention from being focused
on something of quite a different nature, as in the case of a schoolboy
who is about to make a trip and has to do his lessons. But an affect
of fear may just as easily transcend beyond the mark and interfere
with even an adequate reflection. In a critical situation attention often
fails us, the ability to concentrate is usually entirely lacking and fre-
quently also the tenacity, one continually wanders away from the
individual idea, or, like the pupil who is anxiously tr^nng to complete
his lesson, one is distractedby every fly. Frequently, however, tenacity
becomes too great, and the individual is dominated by one single
idea.
A process quite analogous to attention, w^hich is a sort of un-
conscious and permanent situation of the latter, is the association readi-
ness. If something occupies us affectively, then the most various ex-
periences will remind us of it. All kinds of ideas will find associative
connection with this idea, even if it has not become actual in thought.
A person who is afraid of being arrested will easily be frightened by any
one who might in some way remind him of a detective. The association
readiness, like attention, can also be intentional^ fixed on certain
things. Thus I may be searching for something in a book, but I am
also interested in many other things in the book and therefore read
at random, but as soon as I strike the passage upon which I have fixed,
or even something that is only similar, I associate it with the desired

subject.
Mere habit may also produce a sort of association readiness, even
if in a somewhat different sense. Thus a person who is occupied with
much proof reading will easily notice typographical errors in other
reading.
Even normal persons the association readiness often produces
in
deceptions which are very much like delusions, thus a person with a
bad conscience thinks that he is everywhere the subject of observation.
There is also a negative fixation of attention which plays an im-
portant role in pathology. Here one does not wish usually uncon-

sciously ^to consider certain things, or one refuses to take them into
consideration in reflections. The association hostility makes itself felt
in attention.
^^
i) Suggestion
Uniformity of action is not only necessary for the individual with

but even more for a community of individuals.
his various strivings,
Animals, even those living in herds, are apparently unable to com-
municate to one another ideas of a predominantly intellectual content.
Most of their communications are about the approach of prey or of
danger and, as observation shows, this is done mainly through affective
display, which evokes the same affects in the other members of the
herd. It is only through the movement of flight or attack of the animal
first seized with the affect that the others learn the direction of the
prey or danger. This is entirely sufiicient for most cases.
This affective suggestibility is still man, in
fully present also in
spite of his language which has been more and more developed for in-
tellectual needs. Even the infant reacts appropriately to affective
manifestations, and the adult cannot remain cheerfulwhen he is among
sad people, not because of the ideas at the basis of the sadness, but
because of the affective display which he perceives. Because of the
close connection between the affect and the ideas to which it belongs
and because of the influence of the affect upon logic, it is self-evident
that the ideas are very easily suggested along with the affect, quite
apart from the fact that the object of this arrangement is surely also
to transmit the ideas. Ideas without an accompanying affect do not
act suggestively. "The greater the emotional value of an idea, the
more contagious it is." ^^ In conscious suggestion, to be sure, we usually
deal with a "pair" of affects instead of a uniform affect; in the sug-
^Forel, Der Hypnotismus, 6th Ed., Stuttgart, Enke, 1911. Moll, Der Hyp-
notismus, 4th Ed., Berlin, Fischer, 1907.
^^The affect, however, may be present merely in the person subject to sug-
gestion as when a remark, indifferent in itself, touches an affectively toned
complex. A person with an incurable disease hears about a miraculous cure
spoken of in an indifferent or even disparaging tone, and is immediately enthused
to try it himself.
gestor there is the affect of domination, while in the person subject

to suggestion the affect of being dominated or of submissive. Moreover,
in natural suggestions, and even in animals there are also identical
as well as similar reciprocal relationships of affects. Among enemies
the fear of the one increases the courage of the other and vice versa.
Not only thoughts are accessible to suggestion but also perceptions,
such as suggested hallucinations, and all functions controlled by the
brain, i.e. by the affects, such as the "involuntary muscles," the heart,
the glands, etc. The influence of suggestion is therefore much greater
than that of the conscious mill, but it corresponds with that of the
affects.
However, the individual suggestion is not of great importance in the
ordinary life of man. Infinitely more important is the suggestion of
the mass, which even the most intelligent person cannot escape. The
swaying of the masses in political and religious movements is princi-
pally done by suggestion, and not by logical persuasion; frequently
it is even quite contrary to logic. A whole nation is quite incapable of
viewing critically, or resisting suggestions which deal with the instincts
and impulses of preservation, greatness, power, and position.
The psychology of the masses has laws which are quite different
from those of individual psychology. A feeling of community is set in
motion only by impulses possessed by most individuals. The finer
feelings which are developed individually only, cannot come to expres-
sion; thus the masses possess another more primitive morality in the
good as well as in the bad sense. Whereas the feelings become en-
hanced through agreement, the individual's logic not only remains
without any unified connection of the mass, but it is hindered by it;
at most the mass permits it only a subservient part. Reflection, reason-
ing, and the creation of great intellectual and spiritual values of the
mass or of a people originate more from dereistic thinking. Due to
elementary suggestibility the "leader" in the crowd attains great power
in the discovery and accomplishment of ideas. But sometimes he is
only the one who most definitely, most consciously, or most forcibly
perceives the chaotic ideas created by the people, he is merely the focus
of the mass psyche. The more the community increases in numbers,
the more and more does the guiding force become impelled by obscure
instincts, which are not clear to any individual and of which the ma-
jority never becomes conscious. They are likewise difficult to grasp
objectively and resemble much more the evolutionary tendencies of the
vegetative or animal organism, or sudden migrations of animal species,
than actions with a conscious aim. Each individual of a certain race
or period possesses the same tendencies, which burst forth -^"ith irre-
sistible power and stubborn persistency from the "collective uncon-
scious," of which the generally known "spirit of the age" is a partial
manifestation. In chronological succession crowd psychology expresses
itself in traditions, legends, and similar mechanisms only what is com-
;
mon to the various generations is selected and retained.

Suggestion has the same significance for a community as the affect
for the individual. It makes for a uniform striving and provides it with
power and endurance.
Simple habits, as well as examples, can exert very much the same
influence as actual suggestion. One does what one is accustomed to do
without any other reason; one likes to do as other people do without
much thought or feeling in the matter. In the latter case, to be sure,
suggestion, particularly mass suggestion, may easily be a contributing
factor. Viewed from another angle, habit also appears in the form
of Pawlow's association of reflexes (conditioned reflexes), in which, for
instance, secretion of saliva is associated with the sounding of a certain
tone,by letting this note sound a few times at the time of nourishment.
These mechanisms must theoretically be clearly differentiated from
suggestion, although in reality they are frequently mixed.
We also speak of autosuggestion, but this is merely a name for the
effects of affectivity upon one's own logic and bodily function. It is
of greater importance in pathology.

Suggestibility is artificially increased in states of hypnosis which
are themselves produced by suggestion. In hypnosis the associations
are so limited that one only perceives and thinks what the suggestor
wishes, that is, as far as the test person is able to understand his wishes.
On the other hand, the psyche has far more power over the voluntary
associations than ordinarily. The hypnotized person will guess what is
expected of him far better than the normal person. He can utilize
sensory impressions which would be too weak for him in the ordinary
state. He can imagine things so vividly that he hallucinates them,
but on the other hand, he is able to shut off completely from his psyche
actual sensory impressions ("negative hallucinations"). He has

memories at his disposal of which he ordinarily does not know anything.
He frequently also controls in a striking manner the vegetative func-
tions, such as heart action, the vasomotors, the intestinal movement.
All these processes may also be continued beyond the time of hypnosis,
if desired (posthypnotic effects).
Negative suggestibility is the counterpart of the positive. Just as
we have an impulse to follow the suggestion of others, we have as
primary an impulse not to follow or to do the opposite. Children at
a certain age often manifest this negative suggestibility in pure form.
In general, we see it very distinctly in people who have a strong positive

suggestibility, one reason perhaps being that both kinds of suggesti-
bility are two sides of the same characteristic, but also because one is
in greater need of protection through the negative suggestibility, the
greater the danger of becoming a prey to the positive. The appearance
of negative impulses beside the positive is of the greatest importance.
It prevents us from too easily becoming the sport of suggestions, it
protects the child in particular against an excess of influences, it forces

the adult to reflect, and it makes self-assertion possible at every stage
of life.
k) Dereistic ^^ Thinking
Whenever we playfully give free reign to our phantasy, as happens
in mythology, in dreams or in some pathological states, our thoughts
are either unwilling or unable to take cognizance of reality and follow
paths laid out for them by instincts and affects. It is characteristic of
this "dereistic thinking," ''the logic of feeling" (Stransky), that it
totally ignores any contradictions with reality. Thus the child and
sometimes the adult fancy themselves in their day dreams as heroes or
inventors or something else great; in one's night dreams one can realize
the most impossible wishes in the most adventurous manner; and in
his hallucinatory state the schizophrenic day laborer marries a princess.
Mythology finds it quite natural to allow the Easter rabbit to lay eggs
simply because it happens that rabbits and eggs have one thing in
common, namely, they are both sacred to the goddess Ostara as symbols
of fruitfulness. The paranoid finds a piece of thread in his soup which
proves his relationship to Miss Threadway. Reality which does not
fit in with such modes of thinking is frequently not only ignored, but
actively split off, so that, in these connections at least, it is no longer

possible to think in terms of reality. Thus the day laborer as the fiance
of the princess, is no longer a day laborer, but the Lord of Creation
or some other great personage.
In the sober-minded forms of dereistic thinking, particularly in
day dreams, there is very little disregard or transformation of actual
situations, and only few absurd associative connections formed. On the
other hand, dreams, schizophrenia, and to some extent mythology", ex-
ercise far greater freedom in dealing with the thought material, where,
for example, a God may give birth to himself. In these forms dereism
goes so far as to destroy the most common concepts: Diana of Ephesus
is not Diana of Athens, Apollo is split into several personalities, now
he blesses and now he kills, he is a fructifier and he is an artist; indeed,

* Derived from de and reor (away from reality, unrealistic).
he may even be a woman although he is ordinarily a man. The interned
schizophrenic demands damages in a sum of gold which would exceed
the mass of our entire solar system a trillion times. A female paranoid
calls herself free Switzerland, because she should be free. Similarly in
other cases, symbols are treated like realities, and different concepts
are condensed into one. Persons appearing in dreams of normal people
usually have features of several acquaintances a normal woman with-
;
out being aware of it speaks of the "hind-legs" of her small child, which
was due to the fact that she had fused it with a frog.
Dereistic thinking realizes our wishes, but also our fears. It makes
the playing boy a general, and the girl with her doll a happy mother.
In religion it satisfies our longing for eternal life, for justice and joy
without sorrow. In the fairy tale and in poetry it gives expression to
all our complexes. it serves to represent the person's most
In dreams
secret wishes and For the abnormal person it creates a reality
fears.
which is real to him than what we call reality. It makes him
far more
happy in his delusion of greatness, and absolves him from blame if he
fails in his aspirations, by attributing the cause to persecutions from
without, rather than to his own short-comings.

If the results of dereistic thinking seem to be sheer nonsense when
measured by realistic logic, still, as an expression or fulfilment of
wishes, as a provider of consolation, and as symbols for other things,
they possess a kind of realistic value, a "psychic reality" in the above
defined sense.^*
may also be satis-
Besides the affective needs, the intellectual ones
fied in dereistic thinking;but as yet we know very little about them.
Thus in mythology, the sun which travels across the sky has feet or
rides in a carriage. In a certain sense, however, all "needs" are affec-
tive. At any rate, affectivity plays an important role in dereistic
thinking when it attempts to give us information regarding the origin
of the world and the structure of the universe.
In development dereistic thinking seems to be different in
its full
principle from empirical thinking. But in reality one finds all the tran-
sitions, from the slight deviation from acquired associations as is
necessary in every conclusion drawn by analogy, to the wildest
phantasy.
For, within certain limits, independence of habitual trends of
thought is a preliminary condition of intelligence, which strives to
find new paths. And the effort to fancy oneself into new situations,
day dreams and similar occupations are indispensable exercises of the
intelligence.
**Cf. p. 7.
To he sure, the contents and aims of such unbridled mental ac-

tivities always represent strivings which most deeply touch our inner-
most nature. It is therefore quite obvious that dereintic aims are valued
much higher than real advantages, which can be replaced.^'-' This not
only explains the peculiar barbarities of religious wars, but we can also
understand why primitives are fettered with taboo rules, and similar
superstitions, and why they exert the most painstaking efforts not to
leave a particle of their food which could give an enemy the chance
to practice harmful magic on them. We can also see why we find it
difficult to understand how the savage is willing to bear such burden-
some regulations, even if we compare them with Chinese or European
rules of etiquette.
It will be interesting to trace the circumstances which determine
so marked a deviation from reality:
of thinking
1. We think dereistically wherever our knowledge of reality is in-
sufficient for practical needs or our impulse for knowledge urges us to

keep on thinking; this happens in problems referring to the origin and
purpose of the world and of mankind, in problems dealing with God,
the origin of diseases, or evil in general, and how it can be avoided. The
greater our knowledge of the actual relationships, the less room there
remains for such forms of thinking. Questions, such as how winter
and summer come about, how the sun traverses the sky, how the
lightning is flashed, and a thousand other things, which were formerly
left to mythology, are now answered through realistic thinking. 2.
Wherever reality seems unbearable it is frequently eliminated from

our thinking. Delusions, dreamlike wish fulfilments in twilight states,
and neurotic symptoms, which represent a wish fulfilment in symbolic
form, originate in this way. 3. If the different co-existing ideas do not
converge in the one point of the ego to form a logical operation, the
greatest contradiction can exist side by side, there is no question of
any critique. Such conditions are present in unconscious thinking and
perhaps also in some delirious states. 4. In the forms of associations
prevailing in dreams and in schizophrenia the affinities of empirical
thinking are weakened. Any other associations directed by more acci-
dental connections, such as symbols, sounds, etc., obtain the upper
hand, but this is especially true of those guided by affects and all kinds
of strivings.
1) Belief, Mythology, Poetry, Philosophy
Belief is closely related both to suggestion and to dereistic thinking.

The word "to believe" has two meanings: "To accept something as true
'^Cf. the next chapter on "Belief."
;
without logical proof," and "to consider something as probable." We
confine ourselves here to the former concept.
The greatest creeds in religion, politics, theories of social position,
maintained almost entirely through suggestion. Sug-
esthetics, etc., are
gestion is responsible for the uniformity in forms and details,
above all
and to some extent also for the motive power of belief. The origin of
belief always proceeds in accordance with the laws of the affective
mental stream in dereistic thinking. The several great creeds serve
as a definite gratification of general affective needs, and for this
reason they are so easily suggestible and possess such great power
that in most cases one assumes these ideas without any logical
realitic value. We
wish to know that something happens after death
we wish to feel that we can influence fate. The beatiis possidetis
who, in the face of misery, wishes to establish his position on moral
grounds, acts in the same way; and the sick person who wishes
to become well and therefore believes in the quack follows the same
mechanism.
We also differentiate between belief and superstition; the latter
contains a great deal of magic which operates with unknown forces,
while belief has to do more with religion which deals with our relations
to a higher being. But viewed psychologically, there is principally no
difference between them the main difference lies in the valuation which
;
is measured by different standards. Belief becomes pathological only

when it dominates the psyche far too much and when it glaringly con-
flicts with the logical faculties and eventually also with the views of
the individual. But from this alone, and without other supporting
points I should not like to make a diagnosis. The name of prejudice is
applied to false belief or to superstition, when it does not refer contently

to matters of religion, or to one's relationship to fate. This varies from
the prejudices of the people in the recent war to the prejudice of one
individual for another. Prejudice may at first actually be based on a
mere hasty judgment; but it can only derive its power from affective
sources by way of dereism or suggestion.
Poetry and mythology satisfy the same need as belief, with the
difference that the former lays no more claim to direct realistic value
than the day dreams of normal people. Philosophy differs very little
from it, in so far as it actually is pure philosophy. (For there are some
real sciences classified under this name, such as the deduction of logical
and esthetic laws, the theorj^ of cognition, etc.) The current explana-
tions of the optimistic and pessimistic theories as a characteristic ex-
pression of the philosophers originating them, perhaps most clearly
demonstrate the subjectivity of philosophy.
m) The Personality, The Ego

Most of our psychic functions have a continuity, in so far as the
experiences become connected with one another through menriory, and

in so far as they unite with a very firm and constantly present complex
of memory pictures and ideas, namely, the ego, or the personality. To
be exact, the ego consists of the engrams of all our experiences plus the
actual psychism. By we must not merely understand

this, of course,
passive experiences, but also our former and present volitions and
all
strivings; the ego thus really comprises our entire past in a very ab-
breviated form. Still, not all of these constituents have the same value.
At a given moment most of them recede until they lose all effectiveness,
that is, they are not ekphorized ; others are usually, or always present.
The composition of the ego of individual memory images, may be com-
pared to the "public" in a certain restaurant; individual frequenters
may come and go, some are constant visitors, others come frequenth',
and still others have visited the place only a few times. It is true that
I have learned to extract square roots but in my present activity this
knowledge is almost altogether latent. Certain ideas, however, such
as who we are, what we have been, and what we are now, what we strive
for in life, must be constantly more or less clearly present. They are
part of the directive power of our daily actions. The fact that a student
goes to the class at the right time is not merely determined by the idea
of the hour and his schedule, but among other things also by that of
wishing to study, and by the point at which he has arrived in his study.
Thus personality is not something changeable. The component
parts of its ideas change constantly in accordance with momentary
aims, but also in accordance with experiences. There is still a greater
distinction between the strivings of the man and those of the child; and
the destinies oflife such as depression determined b3' inner causes and
even toxic influences (alcohol) may, within a very short time com-
pletely transform the affective part of the personality, which in some
respects is the more important. In a similar manner as in severe
psychoses, the personality may go to pieces in the dream. Some parts
of it fall away and are replaced by others that are quite foreign to it.
Thus a dreamer who in ordinary life is unassuming may feel himself
as being King David, a gentle person may commit a murder, and a
hard-hearted man may wallow in benevolence.
Wealso often attribute to the person a special personal conscious-
ness or a " self -consciousness." ^'^ These two expressions contain two
^^
In popular psychology the expression ''self-consciousness" has a different but
important meaning, namely, estimation of oneself.
I"
;
sets of ideas, theformer represents the continuity of the person, ^the
ego of a normal person has the feeling of being the same through life
the latter deals with the fact of rendering the person prominent and
distinguishing him from the environment, and particularly from other
people. was assumed that the child had no self-consciousness, and
It
to prove this it was argued that the child does not correctly distinguish
its own person, in so far as it speaks of itself in the third person. This
is wrong. In principle the child differentiates itself from everything else
and from other people just like the adult. That it speaks of itself
also
in the third person has its obvious reasons which may be sought in
the manner of teaching language to the child.
n) The Centrifugal Functions

To assert oneself or the genus in accordance with the aim of the
psychic apparatus, to make use of the environment or to defend one-
self against it, is expressed in every psychism in a tendency to react,
or in a striving. In a more complicated being this finds expression
in the form of affectivity. If we perceive something beautiful, we
would like to enjoy it, and if it is unpleasant we would like to ward it
off. Besides this we have a number of strivings which become effective

even without any external cause. Among these we may mention the
impulse to live, the activity impulse, the self-assertion impulse, the im-
pulse for knowledge, hunger, and the sex impulse. The activities in
the sense of these strivings are also connected with pleasure. The in-
stincts of animals evidently represent the same thing. Principally
there is really no line of demarkation between these two kinds of
strivings.
In the countless strivings and exciting experiences many conflicts
and inhibition must frequently arise. One would like to rest and at
the same time drink some water which must be brought from the well
one would like to be virtuous and at the same time get rid of his sexual
tension. Even for physical reasons one cannot do many things at the
same time. The inhibiting effect exerted by contrary impulses upon
one another represents only another special case of the general law,
namely, that central functions not having a similar aim inhibit each
other. But if the force of one impulse is not very much stronger than
that of the other, there results a competition, whereby in the "reflection"
or in the "choice between good and evil" each impulse attracts as-
sociatively the material resembling it, intellectually and affectively.
And under certain conditions it may also attract that which is contrary
to it, in the sense of negative suggestion. Thus arise different func-
tional complexes which act as a whole, and of which one finally asserts
itself and dominates in such a manner that the other is "suppressed."

We designate this as the decision or the act of volition.
In a serious struggle of impulses, as for instance in a decision be-
tween good and evil, the material brought into play includes our virtues
and vices, our entire ethical training, former decisions to be good or to
disregard moral standards, as well as our experiences in former vio-
lations of ethics; in brief, it involves the whole personality; "the
decision belongs to it."
Thus we see that the "will" is entirely dependent on the affects, and
not merely as regards its direction, but also quantitatively. He has a
strong will, who possesses energetic feelings which are not swayed by
every new impetus. By a weak will we understand quite different dis-
positions: (1) it may represent a weak affectivity without motive
power (Abulia), ^^ (2) it may evince an affectivity that is lively but too
labile, too easily changeable, one who follows the crowd and paves the
road to hell with good intentions, or (3) for various reasons one is
unable to form any decisions.

The much mooted question whether there is a "jree will" in the
sense that a decision can be reached without any reason, does not exist
in natural science. We see that the actions of living beings are de-
termined by the inner organization and the external influences reacting
upon them in exactly the same manner as any other happening. There
is no decision which does not have a complete causal basis in motives
and strivings. But motives and strivings are either a complex of

nervous functions, which is subject to the ordinary psj'chic laws of cause
and effect, or something analogous to these nervous processes, which de-
pend on physical as well as psychic causes. "Motives" are causes even
though they are complicated. Science is therefore deterministic even
in those cases where it is not fully admitted. To be sure, we assumed
that one acts badly "because he is a bad fellow^" but we also know
that he himself has not selected his own organization but that he has
inherited it when he came into the world, or that it has been changed
by some influences or other exerted on the brain.
Nevertheless, the subjective feeling of being free in one's decisions
is not an illusion in the real sense. Our actions are the outcome of our
own but as some of these contradict each other, the reaction
strivings,
follows exactly our feelings in the direction of our strongest impulse.
The act of volition is therefore in harmony with the momentary- aims
of the psyche as a whole, that is, with the personality, with the com-
plex, which comprises all strivings and in which the latter can form
a resultant. TTê do what we ivish because we wish what v:e do, or to
"Abulia as a consequence of inabilitj^ to reach decisions, see p. 143.
express it objectively: Volition and action is one process, the two sides
of which are individually rendered prominent. This has an analogy

in the physical sphere, namely, when all the conditions of a process
or a state are present, then the result or the state is also present. It is
a mistake to think that one could wish, that is, act, something else.
However, one can covet only something else. We make this mistake
wherever we form an insufficient estimate of the causes, even in the
physical realms; the concept of accident is based on this. If a brick
falls from the roof and strikes the ground near a person, he says, "I
could have been struck by it."
The dispute concerning the conception of the will is a striking
example of the power of emotions. Scientifically viewed, determinism
is the only possible conception. And yet many people cling to indeter-
minism although they cannot even follow the thought to any clear
conclusion, the moralist, because he has falsely based his ethics thereon,
the theologian because in spite of the contradiction with God's omnip-
otence he needs it for his actual ideas, the jurist because he thinks that
otherwise his laws, particularly the penal code, will be shaken. As a
matter of fact it makes no difference in practice which point of view
one holds. The penal code, for instance, would not have to change a
single one of its provisions, but only a few expressions, if it accepted
the theory of determinism.
Among the various impulses of man the nutritive impulse, which is
a part of the self-preservation impulse, is greatly denatured in our

present condition and therefore difficult to study. But the sexual im-
pulse is still clear to us. It shows us how tendencies of pleasure and
displeasure impel us to actions whose natural aim (in this case the
preservation of the species) may be unwelcome to us, or not become
conscious at all. This is the case, for instance, in the choice of clothing
and most of the other preparatory actions approach of the sexes.
in the
It also teaches us to understand the instincts, which are defined as a
capacity to act in such a manner that certain aims will be fulfilled
without becoming known or without being considered, and without
the necessity of any particular training, acquisition, and practice.
The ethical impulses are of particular importance for every being
living in society. They preserve the community, and hence they often
conflict with the interests of the individuals; they also have a great
many points of contact with sexuality. But it is just as wrong to create
the impression that ethics deals with sex only, as it is incorrect to
follow an ethics of "to &ov7 one's wild oats" and to ignore altogether
the sexual restraints which are originally determined by nature. Never-
theless it is certain that the existing sexual ethics is not adapted to the
demands of modern civilization. Indeed, our form of sofiety on the

one hand and the sexual impulse on the other often conflict in fiuch a
way that even a theoretical solution seems impossible. As a result
conflicts are created which not only are of great importance social. y,
but also medically.
Other definitions of the word "impulse" will be discussed at the end
of the section on Psychopathology.
An effect similar to that of the congenital impulses is exerted by
chance apparatus and habits.'-^^
The other centrifugal functions, such as "psychomotility" and

"motility" we shall pass over as being self-evident.
''See p. 50.
CHAPTER n
GENERAL PSYCHOPATHOLOGY
The symptoms of psychic diseasesshow such an infinite variety of
manifestations that one is them into a certain scheme
forced to put
and to select what is most important in them. For it must be borne
in mind that although superficially two phenomena may look alike,
they may nevertheless have entirely different meanings, depending on
their psychic environments and on their genesis. Moreover, and this
is even more true here than in physical pathology, every symptom is
really only a special part of a general process. What we, for example,
described in the spheres of association, is not simply a disease of the
associations, but a general psychic disturbance, from which we pick
out one part, namely, that which concerns the associations.
For a scientific study of the psychoses it is necessary to distinguish
between primary and secondary symptoms. Thus a paralysis of the
abducens nerve is a primary symptom, whereas the subsequent con-
tracture of the internal rectus and the diplopia are secondary symp-
toms. A certain disturbance of mental function in dementia praecox
is a primary symptom while the resulting twilight state following it
under the influence of an unpleasant experience is a secondary symp-

tom. If a paronoic conceives an indifferent experience in the sense of
a delusion of reference, it is in a certain relation a primary symptom,
but the reaction following it, in the form of an insult which is normal in
itself, is a secondary symptom. The last example also shows that these
concepts are only relative, inasmuch as a fundamental disturbance
often produces a whole casual chain; for the delusion of reference is
already a derivative symptom, in the particular case.
In some diseases it is of value to differentiate between principal and
accessory symptom,s. The former appear in every one of these cases
as soon as the disease reaches a certain height. One must therefore
assume that in mice they are also present even where we do not yet
see them, that because of insufficient intensity they have not yet crossed
the diagnostic threshold. Among these we have the organic symptom-
complexes, in organic diseases, the association and affective disturbances
in schizophrenics, and the manic and melancholic states in manic de-
pressive psychoses. The accessory symptoms, like hallucinations and
54
GENERAL PSYCHOPATHOLOGY 55
delusions, may
be absent in these diseases, or they may appear and
disappear at any time and in any combinations.
1. DISTURBANCES OF THE CENTRIPETAL FUNCTIONS

The centripetal functions may be disturbed through disease of the
peripheral conducting or the central receptive organs. Under the latter
one includes the central sensory fields as well as the whole cortex as
the carrier of the psyche. The disturbances in the conducting organs
can naturally only be disturbances of sensation, while those of the
cortex (respectively the psyche) are almost only disturbances of
perception and the first elaboration connected with it, namely,
apperception.
Disturbances of the Sensory Organs

Disturbances of the sensory organs appear in part as accidental
complications and in part as symptoms of individual psychoses, like
paresis. On the whole they are of no importance in -psychopatholog>%
still, peripheral irritations may occasionally become important by pro-
ducing hallucinations through as yet unfamiliar paths. The patient
is often unable to recognize the origin of his paresthesias, and thinks
that noises in his ear are bells, or what is most common, the false sen-
sations are interpreted in the sense of illusions. Thus buzzing in the
ears conceived as rushing water or as words, shadows and light on

is
the retina as visions of animals, and nervous pains as physical injuries.

Weakness of the sensory organs influences the psyche during its
development and also later. Marked short-sightedness may lead to a
deficiency of perspective or to a lack of consideration of a definite
kind. Thus the miniature paintings of the poetess Annette von Drosta
are supposed to be due to her myopia. Absolute bliridness, naturally,
exerts a very marked influence on the subjective view of the world,
which in the normal person is in the first place optic; it does not. how-
ever, change the psyche in its relations to people.
It is quite different in the case of deafness or disturbances of hear-
ing. With the exception of the modern way of teaching the deaf and
dumb, we perceive the whole cultural achievement of older generations
directly or indirectly through hearing and all our relations to human
environment are regulated through language. (Writing presupposes
language.) Hence the deaf person, without special instruction, remains
a psychic cripple in the most important relations, even if he is intelli-
gent; and as he is unable to put the correct value on the behavior of
his environment, he becomes irritable, hot-tempered, and suspicious.
Even acquired difficulties of hearing change the psyche in both of these
directions, wherein suspicion is most prominent and may even rise to
the degree of delusions.

Central Disturbances of the Sensations and Perceptions. Sen-
sations are seldom disturbed through psychotic processes. In
melancholic and neurotic states we often encounter a more or less
general hyperesthesia. The patients not only suffer much from the
usual sensory stimuli, but they also falsely interpret the stimuli. Thus
a dim light may seem glaring, knocking on the door may be conceived
as shooting,and the sound of a fountain may be taken as the hissing
of the escaping steam from a locomotive. Hysterical and hypnotized
persons may, under certain conditions, react to the slightest sensory
impressions in a manner unperceived by normals.
Hyperalgesia too, is present in the same conditions and also as a
result of organic processes in the nervous system.
Hypalgesia and Analgesia are quite common; they are centrally de-
termined and present a great many different types.
1. In coma of epilepsy and other diseases, it is assumed that there
is an absence of consciousness and hence pain can be as little perceived

as anything else. In soporose and torpid states the threshold of feeling
is generally raised and the perceived stimulus, too, is of lesser value
than in normal states.

In strong affects attention may be so one-sided that one may not
2.
feeleven the most severe pain; thus the officer may first become cog-
nizant of his shattered arm when he attempts to brandish his sword.
Maniacal patients often injure themselves when in an excited state
without noticing it; but when their attention is directed to the pain
as in a minor operation, they evince great suffering. The complete
analgesia which one often observes in alcoholic deliria, perhaps also
belongs here.
3. Hysterical mechanisms can shut off altogether the feeling of
pain or confine it to a circumscribed part of the body.^ But in
contradistinction to those evincing organic analgesia the hysterical
patients do not injure themselves, for the feelings are only shut off
from the conscious ego but continued to function in the unconscious
orientation.
4. Peculiar is the analgesia in some catatonic patients which extends
over the whole body and can be so absolute, that intentionally or acci-
dentally, the patient may sustain the most severe injuries. It may
come and go very rapidly and is thereby independent of conscious at-
*This is not to be confused with the pleasure in fain m some hysterics and
masochists.
GENERAL PSYCHOPATHOLOOY 57
tcntion. But even here, one perhaps deals with a blocking of feeling,
of psychogenetic nature.
5. Hypalgesias and analgesias in general paresis are mostly confined
to the skin, while the deeper structures remain sensitive. A paretic
can bite out pieces of skin from his hand in order to tease the attendant,
but he is extremely sensitive when an effort is made to move his anky-
losed joint. The diminution or absence of sensations are to some extent
mostly dependent (but not principally so) on attention. We have no
comprehension for this form of analgesia.
Other hypesfhesias and anesthesias are not common in the
psychoses. Hysterical blindness, deafness, and similar afflictions are
based on (auto-) suggestion. Depressed patients sometimes complain
that their food has no taste, thatit feels like chewing straw or paper,
that all colors look equally grey as if covered with ashes, but when
one examines their sensations they are found to be normal. The same
phenomena may be produced in normal persons through a strong de-
pressive affect.^
We omit here the aphasic and agnostic disturbances because they
surely belong to the pathology of the cerebral cortex and not to the
symptomatology of the psychoses, even if they sometimes accompany
an organic mental disease.
Perception and comprehension show the following disturbances in
idiots. Idiots cannot comprehend anything complicated. They see
the elements of an object but not the whole thing. Or they recognize
pictures with difficulty or not at all, while they can readily identify the
same things in nature ; they often lack the understanding for perspective
imagery.
Perception may be imperject. In a clouded state, catatonics and
especially alcoholics, may perceive a green head of cabbage as a rose,
a cucumber as a sausage, and an ear of corn as a fir-cone. All this is
due to the fact that they do not comprehend the color or the size in
the whole picture-complex. On the surface these disturbances resemble
illusions, but theyfrom them through the fact that the alteration
differ
of the picture has no meaning to the patient and is the same as falsifi-
cation produced by carelessness. The mistake that brings about the
illusions has a definite aim.
When apperception in the optical field is made difficult by exposing
pictures for a very short time, the following will be noted: In organic
psychoses the perception needs more time and even then the patient
'
Cf. Goethe (Kanonenfieber bei Valmy) "The ej-es lose nothing in force
:
and clearness; but nevertheless it is as if the world assumed a distinct brown-

reddish tone."

often
makes mistakes. In epilepsy the behavior is the same. There
seems to be some difference but it cannot be definitely fixed. At ail
events the symptoms correspond with the general retardation of the
psychic processes in the patient. In both groups the tendenc^^ to per-
severation expresses itself in the fact, that a later image is mistaken for
one seen before (paraphasic disturbances should here be excluded) In .

alcoholics the answers mostly follow quickly and with subjective sure-
ness; nevertheless mistakes are frequently made and sometimes they
show that the somehow reached the psyche. Thus mistaken
real picture
objects are named which, although they show no optic similarity to the
picture exposed, they nevertheless are in some way related to it. For
example, the picture of an axe brings the answer shovel, or the image
of a number may evoke an entirely different number. In all these
diseases the results may be improved through exertion of attention,
so that one is often inclined to ascribe such mistakes to inattention

which would be incorrect. In profound melancholic states the apper-
ception must be given more time if one wishes to avoid an abnormal
number of mistakes. Manic states show nothing characteristic in the
habitual perception of their environment, and in tests conducted with-
out accurate measurements. In laboratory experimentation the
patients perceive things incorrectly and make more mistakes than
normal people: this probably does not depend on perception but on the
flightiness of attention and similar factors. Nor are we aware of any
real apperceptive disturbances in schizophrenia; the mistakes which
occur here so often can be regularly explained by the state of compli-
cated functions of attention, affects, and thinking.
Analogous disturbances, though not so easy to demonstrate, are also
found in the acoustic field. In organic patients particularly, one is
often struck by the fact, that questions must be often repeated before
they are correctly grasped; this is especially true when one changes to
another theme.
The most important psychopathic manifestations in the centripetal
fields are thesensory deceptions. (Phantasms.) They are divided into
Illusions and Hallucinations.
Illusions are real perceptions pathologically changed. The striking
of the clock becomes an insulting remark or is conceived as a promise;
the grasped hand is hurled back because it feels like a dead hand; people
are seen walking on their heads; instead of the white color of the face,
itlooks black, and instead of the nurse one sees a waitress. The real
mistaking of personality where some one of the environment is looked
upon as a relative or acquaintance of the patient, or as the president,
is rarely a pure illusion; often it is a delusion, as in schizophrenia, and
occasionally it is a semi- or total conscious playfulness as in mania.

Most frequently it is a process belonging to confabulations, as in
organic psychosis.
The illusion is a caricaturing of a normal process. In ordinary per-
ception it is only exceptional that we perceive all the qualities of a thing
in question; the missing parts we unconsciously supplement and those
that are falsely perceived are corrected in the sense of the whole
thing. Thus even the normal perception is a sort of illusion. It is very
difficult not to overlook a printer's errors, and the telephone certainly
does not give us all the consonants with the required clearness; we
supplement them without being aware of it. It is only a difference in
quality, when during a markedly affective situation a tree stump is
taken for a highway man, or a fog for an apparition of an angel, and
yet the last examples can no longer be differentiated from the illusions
of insane patients.
Hallucinations are perceptions without corresponding stimuli from
without. Everything perceived can also be hallucinated, and indeed,
this may be achieved in a manner, that the elements form free
combinations; thus a lion may have wings, and a figure may be
composed from different persons. Besides, morbid func-
of attributes
tions apparently produce inner feelings, which never occur in any
other way.
The theoretical distinction between hallucinations and illusions is
not always self-evident. No sense organ is ever quite without

a
stimulus ("Light, dust" of the dark fields; entotic noises, etc.), so that
one can almost always speak of a false interpretation of a sensory im-
pression. As a matter of fact, the so-called visual hallucinations of
alcoholic deliria are illusions based on irritations of the senson," appa-
ratus. But as the stimulus does not come from without it is counted
among the hallucinations. In hallucinations of smell and taste one can
hardly ever exclude sensations of smell and taste the skin ; is constantly
touched by the clothes, currents of air, as well as similar stimuli.
One cannot decide whether one deals with hallucinations or illusions
in the case of voices coming "from" the whistling of the wind or the
rattle of thewagon, which are perceived simultaneously with the noises
causing them.
In most cases the differentiation is simple. Visions which are not
connected with definite objects are undoubtedly hallucinations, the same
is true of words which are heard as coming from the wall, and this is
especially confirmed in both cases when the optic and acoustic nerves
furnish beside a great many other stimuli.
Hallucinations may be graded according to three directions: the
clearness of the projection to the outer world, the clearness of the per-
ception, and the intensity. These qualities are independent of one
another.
The projection to the outer world is usually perfect. What the
patients see and hear they accept as impugnable reality, and when
hallucination and reality contradict each other they mostly conceive
what is real to us, as unreal and falsified. It is of no avail to try to
convince the patient by his own observation, that there is no one in
the next room talking to him; his ready reply is that the talkers just
went out or that they are in the walls or that they speak through in-
visible apparatus.
However, hallucinations evince all gradations. There are hallucina-
tions which are recognized as hallucinations but are none the less
perceived with perceptible distinctness (Kandinsky's Pseudo-hallucina-
tions) others concerning which the patient cannot say whether they
;
are visions or vivid imaginations, whether they are voices or "inspired"

thoughts ("psychic hallucinations"), and so they gradually shade off
until they reach the usual thoughts and ideas.
The patients often localize in the body the voices, and sometimes
also the visions (mostly in the chest, sometimes in the head, and oc-
casionally even in any other part of the body).
Projection is facilitated through a high perfection of the image. Still
hallucinations often show the vagueness of ordinary ideas although the

;
patient often sees, definitely, a "dog," he is nevertheless unable to tell

anything about the breed, color, size and the position of the dog. While
the patient himself is never conscious of this deficiency, it may furnish
the physician important suggestions that we deal here with an illusion.
One cannot, however, reason the other way, for there are also hallucina-
tions endowed with the perfection of an actual perception.
Remarkable are the "extracampine" hallucinations which are
localized outside of the sensory field in question. In the nature of the
thing one deals mostly with visions, the patient sees with perfect sensory
distinctness the devil behind his head, but it may also concern the
sense of touch; thus the patient feels how streams of water come out
from a definite point of his hand. Whether come
voices which seem to
from thousands of miles should be designated as extracampine or not,
is arbitrary.
Sometimes, and this is most frequent in alcoholic deliria, the dis-
tinctness of the projection fluctuates with the intensity of the disease,
instead of real things, the convalescent alcoholics see in the hallucina-
tions only "images" which are shammed for their benefit; other patients
maintain that the voices are only produced to deceive them or they are
"dreams." Still such indistinct projections arc also present at the

height of the disease.
Intensity fluctuates from the loudest reports of a cannon to the
hardly audible whispering, from the most glowing light to the dimmest
shadow. During actual attacks, especially in schizophrenia, the in-
tensity may rise and fall with the intensity of the attack.
The distinctness is sometimes extremely obtrusive; it may, how-
ever, sink to dissipating cloudlike figures, to confused voices and in-
distinct whispering, for the understanding of which the patient is forced
to exert all his attention. At all events the patients seldom conceive
the indistinctness, for they understand what the hallucination tells
them.
Of other qualities of sensory deceptions the following may be men-
tioned: the visual hallucinations of alcoholic dcliria which show a
tendency to be moving, multiform, small, and without color; the visual
hallucinations of touch, in cocaine insanity are often microscopically
small. Visions showing a tendency to become greater and greater and
which at the same time in most cases seem to come nearer and nearer
are usually connected with anxiety.
Hallucinations may be changeable or stable. The voices are often
abrupt and fragmentary. Auditory hallucinations put together in a
dramatic fashion point to alcoholism, particularly alcoholic insanity.
Connected hallucinations which fit together, accompanied primarily
by visual illusions are found in hysterical twilight states, and also in
other cases. Occasionally one finds one-sided hallucinations, particu-
larly in one-sided lesions of the sensory organs or of the sensory fields
and tracks in the brain.
The relation to the real perceptionvaries. Voices can naturally
be localized anywhere, in the next room, in the walls and in open
spaces. Visions come in conflict with reality. Thus, behind the
hallucinated man one cannot see anything of reality, or he appears
transparent (ghosts). A hallucinated person can be placed in the
midst of reality. Thus a skull may be seen over the shoulder of a
neighbor, etc. In most cases, however, the manifestations are inde-
pendent of reality. The whole environment may be changed halhicina-
torily. Thus a patient imagines himself in heaven instead of the
observation ward.
The patients are often cognizant of the hallucinations, not exactly
that they are false sensations, but they feel that there is something
strange about them. Thus they know them through their different
content, they state that they have feelings that they have never ex-
perienced before, for the expression of which they have to coin new
words. They feel that they see remarkable images and scenes, ab-
normal localizations, voices in the walls or in their own arms, a light
in their own body or in the uterus of a passing woman. They also

recognize the strangeness through indefinite projection to the outer
world. The patient believes that he hears through his leg and not
in his ears ; he does not know whether he touches an animal or sees it.
Therelation of the hallucinations to the other mental content is

remarkable. At the height of the disease the hallucinations in most
cases have not only the reality value which is unimpugnable to the pa-
tient but they also have contently a compulsive power. Thus if a
healthy person would hear a command ("Kill your child"), it would
never occur to him to follow it, but the patient obeys it with or without
resistance. That has nothing to do with the form of the command,
with the clouding of consciousness, or with the dementia, for the last
named conditions are often absent, but it is due to the fact that the
hallucinations originate from the strivings belonging to the personality
of the patient. It is for that reason that the patients find it so difficult
Thus a paranoid patient suffering from
to ignore their hallucinations.
pneumonia does not bother about the inflammation of the lungs, but oc-
cupies herself with the hallucinated prolapse of the rectum; a real mis-
fortune is barely noticed while the hallucinated one lays claim to the
whole personality. On the other hand, patients in an alcoholic delirium
often view their conditions like an audience in the theatre, and de-
mented schizophrenics may even constantly hallucinate and apparently
pay no attention to it.
Because the hallucinations really only express the thoughts of the
patient, be they conscious or not, it is quite comprehensible how definite
explanations are readily given to apparently incomprehensible hallu-
cinations. Thus a patient hallucinates the word "clean," nothing else,
and becomes very excited over it because one means to tell her by this
word that she has soiled the bed. A great many definitely recognize
poisons in hallucinated odors and tastes, the real odor of which they
do not at all know.
This also shows the possibility of teleologic hallucinations which
give the patient good advice or warn or prevent him from doing some-
thing which would harm him. Thus the dead mother holds him back
at the last moment from committing suicide, an hallucinated physical
resistance preventshim from throwing himself out of the window. The
Maid of Orleans is told by the Holy Virgin what to do in order to
conquer, but this only took place as long as the war situation was so
simple that the girl's reason could grasp it.
A similar situation prevails when the so-called "voice of conscience"

criticizes the actions and thouf^hts of the patient, be they just or evil.
Sometimes warning and enticing, friendly and hostile voices, become
separated into two persons which are endeavoring to persuade the
patient.
Whereas in one case the hallucinations appear quite strange to the
conscious personality of the patient, a circumstance which he uses as
a proof for the exogenous origin of the voices, "Such thing I really have
never thought of," in another case they are intimately connected with
the patient's thoughts. The latter case is most pronounced in the
so-called "thought-hearing" (wrongly called "double thinking"), where-
by the patient's own thoughts seem to be uttered by others. This
occurs frequently during reading. It is remarkable that the voices
can also utter what is contained in one or many lines perceived by the
eye at the time.
Some patients are filled with their hallucinations and can talk of
nothing else, while others either will not or cannot give any informa-
tion about them. This is particularly true of schizophrenia where the
hallucinations or the memories of them are easily blocked from the
other content of consciousness.
Many patients assume as facts even the most nonsensical hallu-
cinations. Others seek to explain them by machines, or by distant
physical effects of all sorts. Nowadays one seldom hears of demoniacal
influences. Some patients, who feel that their thoughts are read by
others imagine themselves to be transparent. Still others believe that
hearing voices signifies the attainment of a special faculty.
Causation of hallucinations. Hallucinations accompany many
mental diseases, toxemias, marked exhaustions, and normal sleep. In
the psychoses their appearance is facilitated by an absence of sensory
stimuli, thus the darkness of the night favors visions, and the quietude
of the prison auditory hallucinations. On the other hand, real stimuli
sometimes act as exciting causes, thus auditory hallucinations may
appear even during a noise. Many patients close their ears in order
to hear the voices well, and others in order to rid themselves of them.
Occupation (distraction of attention) sometimes hinders them and
more seldom promotes them.
Exogenous experiences as well as thoughts may give rise to hallu-
cinations and determine their content when it is more a question of
heightening of the momentary'- disposition. Thus the patient seeing
dishwater carried past him, hallucinates the insulting remark "food-
spoiler," or seeing the grass cut, he feels himself cut with every" stroke
of the scythe. Other patients feel themselves "spooned in," if some
one eats near them, or hearing a key turned in the lock they feel it
painfully in their hearts. As a perception in one sensory field produces
hallucinations in another field, one speaks in such cases of Reflex
hallucinations. This is certainly an incorrect conception of the
mechanism.
Visual hallucinations (visions) usually come in conflict with the
surroundings and may also be corrected through other senses (touch,
resistance). They are therefore rare during the day and in clear
patients, but they easily dominate delirious and twilight states. At
times they lack the third dimension, and more than any other hallu-
cinations they show an indifferent content. Thus the patient imagines
that he witnesses a theatrical performance which has nothing to do
with him.
It is quite different with auditory hallucinations. In language they
express as voices all things that move man: The patient is abused,
insulted, threatened, and hears the wailing of maltreated relatives;
on the other hand, he also receives joyous promises, orders, and other
messages. He can enter into conversation with the voices, but in most
cases he need not talk loudly to them, they answer even to his thoughts.
The voices communicate with the patient from any distance, and
through all possible hindrances by means of the most secret paths and
through apparatus, especially invented for this purpose. "The voices"
not only talk but electrify him, poison him, and make thoughts for
him; they become embodied in the persons who have any dealings with
him.
Auditor}^ hallucinations without words are not so prominent. In
ecstasies, fever deliria and especially in delirium tremens, one often
hears music and singing but otherwise one rarely encounters this type
of hallucination.
Hallucinations of smell and taste rarely appear alone. In ecstasies
and occasionally in the later stages of manic paresis, they enhance the
great pleasure; in schizophrenic delusions of persecution they reveal
some disgusting and some poisonous substances, including also pitch
and sulphur. Other tastes and smells are only very rarely hallucinated.
Cutaneous sense. The sense of touch {''Haptic Sensory decep-
tions") hallucinates vividly only in delirium tremens, where small
animals, bugs, tight bands, and mucous threads are felt. They are also
found in connection with bodily hallucinations, inasmuch as snakes
which crawl to the genitals, blows, stabs, and similar hallucinations are
also felt by the sense of touch. The other qualities of the cutaneous
hallucinations are still more difficult to differentiate from the following:
Hallucinations of general sensations of the bodily organs are wont
to appear in great numbers in schizophrenia. The patients feel, how
their liver was turned, the lung sucked dry, the intestines torn out, the
brain sawn apart, and the joints stiffened, or how they are beaten,
burned,^ and electrocuted ("physical delusions of persecution"). Here
belong also the very common sexual hallucinations, which seldom cause
pure pleasure, but mostly great pain. The patient feels that his
"nature" is drawn from him, his genitals are squeezed, and his semen
is driven inside of him. Women feel themselves violated in the worst
way.
The physical hallucinations can be differentiated from paresthesias
mostly through the fact that the patients feel the former as "done" from
without.
Some authors associate the physical hallucinations with the self-
preservation impulse, with the affectivity; they are supposed to be in
most intimate relation to the ego. There may be some truth in this,
but what, is difficult to say.

Hallucinations of kinesthetic sensations are most frequently seen in
delirium tremens, where the patients imagine that they are at work
while they lie in bed. It also happens, that they suddenly feel their
seat swinging under them, or see objects moving. Schizophrenics may

have the feeling that one of their joints is moved. Instead of expressing
themselves in voices, the thoughts sometimes manifest themselves in
kinesthetic hallucinations of the speech organs, so that the patients
imagine that they say something while in reality their speech apparatus
remains quiet. "Vestibular" hallucinations produce the feeling of
floating and falling.
Also pains can be hallucinated, but it is not always easy to differ-

entiate them from other functional pains.
The hallucinations of the various senses frequently combine with
one another; thus one sees and hears a man and feels his influence, or
one sees and touches objects.

As elementary hallucinations in the optic field we designate such
unformed visions as lightning, sparks, and cloudlike partial darkening
of the visual field, and in the acoustic field, the simple noises such as
murmurs, knocks, and shooting.
Negative hallucinations, or not to perceive an object which is acces-
our senses, are rare occurrences in pathology but they can easily
sible to
be produced in a state of hypnosis through suggestion.
"Retroactive hallucinations" is another name for hallucinations of
memory.
Many authors include under the hallucinatory disturbances also the
'Continuous uncontrollable burning in the form of paresthesia is mostly a

symptom of a brain lesion.

secondary sensations or synaesthesias. The peculiarity of the latter
the fact that sensations of one organ are accompanied by sensa-
lies in
tions of another sensory field. The most common form is "color

hearing," that is, a feeling of color on hearing of sounds or the vowels
("photism"). However, the secondary sensations have nothing to do
with hallucinations and in any case they have as yet no meaning in
pathology.
The theory of hallucinations is very instructive. There are still
psychiatrists who cannot think of an hallucination, that a pro- is,
jection of ideas with perceptible distinctness into space, without the

cooperation of the peripheral sense organs. For they maintain that
under normal conditions only those processes can be projected to the
outer world which are accompanied by the corresponding sensory
stimuli. But since, as far as we know, we only perceive processes in
the cortex, directly "through consciousness," this conclusion is not
binding, and, aside from other reasons, is false, because one can also
hallucinate when the peripheral sensory organs are destroyed.
It is then assumed that there are perception cells or perception
centres in the cortex; and that when they are normally put into
"strong" activity by the periphery they produce sensations and per-
ceptions in the organ of thought (the whole cerebral cortex) and when ,
put into "weak" activity they give rise to ideas. If we could speak
at all about the "strength" of such processes we would say that it haa
nothing to do with the difference between perception and ideas. And
principally it has just as little to do with localizations. Even the
simplest psychic element, as, for example, the sensory sensation of blue,
is a far reaching psychic elaboration of the mere incoming stimulus;
just let us imagine the process of singling out the individual color feeling
from the chaos of all synchronous sensations and psychic processes in
general. The pure sensory element of perception, as the most vivid
idea or hallucination, must perforce be something just, or nearly, as
diffuse as the "idea." Nor is the most essential part in the "projection
to the outer world," in the "reality judgment," which lies in perception,
or in the substantiality of the latter. In the case of artists or in pseudo-
hallucinations, "ideas" may be so clear, so sharp, so detailed and vivid
in color, tone, and in all other sensory qualities that in this regard they
differ in no way from perceptions, but they, nevertheless, lack the
reality character of hallucinations or perceptions. Conversely, the
accuracy and substantiality of the psychic structure may be absent in
sensor>' perceptions (in fogs, dawTi, etc.), may show
and hallucinations
so much resemblance to themost flighty ideas, that the patient could
not say definitely in what words a hallucinated thought was heard,

and nevertheless it may have such an unshakcable rcahty judgment,

as if I saw my own hand in front of me in broad dayli^^ht. The reality
judgment, the substantiality of a true or hallucinated perception,
depends almost altogether on the psychic environment. The difference
between perceived and imagined space is an invention of speculative
psychology. If I looked at the table and then turned my back on it,
it still exists for me in the same true reality, and in the same place as
at the moment before, when I looked at it. The same holds true when
I look at a coin on the table and then cover it.
At all events, the ideas represent reality to the naive consciousness

just like the perceptions, although one soon learns to make a certain
distinction between them. One also reacts to them as to perceptions
they have the meaning of timely prolonged perceptions. If I run away
from a persecutor, I need not see him or hear him ever>' moment. Thus
we understand the continuous scale from the most abstract idea to the
one with sensory distinctness of the pseudo-hallucination. The more
one abstracts from the sensory components and from the details of a
physical idea, the lighter is the "sensory distinctness." The latter does
not, however, altogether determine the reality judgment and the sub-
stantiality, although it naturally may contribute to the conclusion that
a manifestation is "real." Besides this there is another scale, which
can more or less definitely furnish substantiality to an idea regardless of
whether the latter has sensory vividness or not. However, the distinc-
tion is less delicate here, in most cases one is simply confronted with the
absolute question, "real or not?" The appearance of a saint is con-
ceived by the normal minded modern person as a vision (= pseudo-
hallucination), whereas the devout may consider it as a real mani-
festation of the saint.
We must distinguish two types of hallucinations. The first repre-
sents ideas projected to the outer world; this is the hysterical type.
The second type represents illusionally misinterpreted paresthesias.
Thus the irritations of the optic organs in delirium tremens produce
visions of animals while those of the cutaneous nerves, perceptions of
threads or needles; in schizophrenia the processes of the brain lead at
first to paresthesias and hypochondriacal sensations, and then change
to physical hallucinations as the disease progresses. It is noteworthy
that the relations of the hallucinations to the ego are very close in
schizophrenia and in dreams and very weak in alcoholic insanity and
even in some organic diseases. Delirious patients often regard their
hallucinations as a moving-picture show. Another remarkable thing is
the fact that the manifestations in alcoholic deliria are mostly colorless,
while similar appearances in paresis and other organic insanities more
frequently show color the patients speak of variegated butterflies, red
;
powder spread all over, and blue threads. Hence the second type
belongs to hallucinations only insofar as its basic sensory stimulus
originates in the body itself, whereas if conceived in the pure psychic
sense one deals with simple illusions.
Most of the elementary hallucinations are likewise misinterpreta-
tions of irritating states of the sensory apparatus, nevertheless it is
naturally also possible that the hallucination of shooting, of running

water, or lightning could sometimes also result from an idea.
2. DISTURBANCES OF CONCEPTS AND mEAS

Persons who mute naturally lack the
are congenitally blind or deaf
respective sensory components in their concepts. Even shortsighted
people must perforce perceive many things somewhat differently from
those who have full vision. Some assume that one cannot remember
odors and tastes, still in many persons such memory pictures form a
part of the concepts of foods, flowers, and similar articles smelt and
tasted. Whether this or that sense predominates, undoubtedly depends
largely on individual idiosyncrasy. In some it is the optic memory''
pictures which constitute the most important components of their con-
cepts and hence of their thinking, in others it is the acoustic, and in
still others it is the motor memory pictures. These differences are of
importance in the pathology of cerebral localization, for a person
belonging to the extreme "visual" type having a lesion in the occipital
lobe is deprived of the most important components of his concepts and
hence sustains a greater loss in his psychic functions than one of the
extreme "auditif" type.
Due to a poverty of associations congenital defectives cannot make
full use of their experiences in the formation of concepts, and conse-
quently are connect and combine the individual memory

less able to
pictures. Whateven of much more importance is the fact that they
is
do not sufficiently comprehend the concepts which others convey to

them through speech. In this respect deaf persons are worse off, even
if they are endowed with good intelligence. Both classes therefore form
less concepts than normal people, and they are very apt to put an
incorrect limitation on them. They act like little children who may
put into the same concepts, let us say, the duck and the hornet
because both fly, and regard the caterpillar and butterfly as different
animal species. They also form insufficient, unclear, and inaccurate
limitations; they cannot, for instance, distinguish between "state" and
"country," or even between "sparrow" and "finch." These wrong and
insufficient differentiations are, of course, much more r-ommon and more

profound in idiots than in deaf people, for the former do not note small
differences and are unable to discriminate between essentials and un-
essentials. Nevertheless most concepts formed by idiots are not at all
unclear; this is not only due to the fact that they form only simple
concepts, but chiefiy because they do not go far from things tangible,
and form few abstract thoughts.
However, there are types of congenital defectives, in whom the most
essential deficiency is a lack of clearness in concept formation, but they
have not as yet been sufficiently studied. Thus an erethic imbecile
defines the concept "valuable" as: "When you knock it higher (raise
*
the cost), it will cost even more."
The more complicated more remote its com-
a concept and the
ponents are, the an imbecile to form or to grasp
less possible is it for
the same; he might in some case understand the idea of "family" but
not that of "state." However, it would he incorrect to state that idiots
and imbeciles form no abstract concepts, but it may be said that they
do not form complicated abstract ideas, and that frequently their
abstract concepts are falsely construed. Those of a lower order may
grasp the concept of "father" and "mother," but no longer the concept
of "parents"; they can thoughtfully state: "John hit me and I hit
John," but they are unable to comprise this reciprocal activity under
the term "each other" or "one another."
Here, however, the difficulties of language must be distinguished
from those of concepts. This is not always easy, even in normal people.
The differences of personal disposition, of education and especially those
of race are very great. The disposition and education of the French
is such, that a schoolboy there may talk very nicely about things, of
which he has at most a very meagre understanding. In the German
part of Switzerland with its clumsy expression, the intelligence of
foreigners is at first frequently overestimated in our Swiss clinic Ger-
;
mans, who are more fluent in speech, are not unfrequently diagnosed as
manic cases, and real manic patients often seem much richer in concepts
than they are.
A good fluent speech, congenital or acquired, often disguises real
deep defects of intelligence, be it in society, in school, or even in the
highest examinations, which only goes to show how imperfect these
organizations are. In such cases one speaks of higher dementia.^ and
persons so afflicted sometimes play a great part in life. Thus a famous
"Nature Healer" belonging to this category'", reduced ever>-thing to the
"Cf. Also below the "Nature Healer" with his "Principle of Contrasts."

Cf below Oligophrenia.
.
"Principle of Contrasts," but he could not distinguish between "con-
trast" and "difference," between "power" and stimulus," between
"health" and "feeling of health." In more difficult matters such con-
fusions of ideas may be encountered even in the most intelligent class;
the frequent confusions in the deductive sciences are mostly due to the
fact that two somewhat differing concepts are connected by a common
designation and are then interchanged.
Thus one may admit, that behind the properties of the psyche, there
must be a carrier of the properties, a "being." But if one then deducts
from the concept of the "being," that the psyche is punctiform, lacking
space and time, one finds suddenly that instead of the above concept
of the "being" or the carrier of the observed psychic properties, another
concept has been substituted, the origin of which one does not know and
concerning which it must be proven that it is applicable to the relation-
ships of the psyche. Another excellent false deduction can also be seen
in the following reflection:Cancer may be caused by a cold; for all
physiological reactions, hence also those leading to cancer are con-
ditioned by an "irritant," and cold is surely an "irritant."
Symbols or concepts having one or many common components, are
also used by normal people, but more so by patients. This gives rise to
many coarse errors of thought, for instead of conceiving something as
a mere figure, it frequently takes the place of the original concept,
thus the fire of love is seen as red-hot, or the patient actually feels
it burning him.
In psychoses, concepts may be profoundly distorted. "Right" to a
litigiousparanoiac is usually what suits him, and "justice" becomes
hypertrophied in the epileptic patient who feels justified in almost
killing another patient, because the other brushed against the attending
physician in passing. A conglomerate of concepts, as well as markedly
distorted concepts are found only in schizophrenia and in states of
clouded consciousness. Nevertheless one observes nothing here that
cannot occasionally be found everywhere to a lesser extent.
Many patients experience things which are unknown to normal
persons, for which the patient must create new concepts. Thus a
paranoid praecox said that the "Double polytechnic" is her highest
and accomplishment which she claimed as her due reward,
intelligence
meaning the path of
or another patient speaks of the "Dossierpath,"
the hallucinatory influences. New concepts are sometimes created
through the process of "condensation" in so far as attributes of many
persons are fused in one.
The mental elaboration of concepts is frequently imperfect, espe-
cially in dementia praecox, which causes temporary mistakes, thus
barrel and hoop, or even father and mother, may be identified with
one anotlier.The boy who phiyed sexually with the patient in her
childhood, her lover, her seducer, two physicians in the asylum to

whom she transferred her love, all these are thought of by the patient
as one person. In most of these cases we do not deal with a permanent
injury. That an advanced paretic can no longer think of a compli-
cated concept like "logarithm" or even "state," in its totality, is nat-
urally the result of a disturbance in his associations. Nevertheless, an
actual destruction of the concept has not yet been demonstrated in the
psychoses. If a patient looks upon the attendant as his sister, it is
not the result of a disturbance of a concept, but it is due to an illusion
or delusion.
At all events, the anomalies in the formation, retention, and in the
transformation of concepts have not yet been sufficiently studied.
Disturbances of ideas naturally exist insofar as the psychic proc-
esses in general are disturbed. Disturbances of perceptions, of memory
pictures, and mental stream, must secondarily lead to disturb-
of the
ances of ideas. Moreover, it actually happens that the specific quality
of ideas becomes blurred by the fact that the ideas become transformed
into hallucinations, or they are mistaken for earlier experiences.
3. DISTURBANCES OF ASSOCIATIONS AND OF THOUGHT

General Facilitation of the Psychic Processes. Flight of Ideas.
Even normal persons who are "in good humor," or "stimulated"

sometimes give the subjective and objective impression as if their
thinking process ran with particular ease. Such people have more to
say, and sometimes utter thoughts which are not habitual to them,
especially jokes, even quite daring ones. To be sure, such performances
cannot always stand the test of criticism. In pathological states,
mostly in connection with euphoria and exalted self-reliance, we often
find a morbid exaggeration of the afore-mentioned state, which is
designated as flight of ideas. Here the most striking phenomenon is
the exaggerated distractability which at first comes from within but
,
later also from without. The patients change their objective idea with
abnormal frequency, and in the most serious cases it follows every
thought uttered or indicated. Thus a patient wishes to tell about a
trip to the Righi Mountains and he suddenly thinks of the donkeys
which were used there before the construction of the railroad, then of
salami sausage supposed to be made of donkey meat and then of Italy
where these sausages come from. In less severe cases the patient is
able to revert to the original theme, or he merges into a thousand and
one things, being unable to bring a single thought to completion. But,
except in the most difficult cases where the patient's thoughts can no
longer be followed, or where the intermediate connecting thoughts are
not uttered, one can understandhow thought is distracted. The sec-
ondary associations which also appear in normal persons but which
they suppress, absorb the patient to the same extent as the principal
theme.
The reenforced distractability from without may be lacking, but in
most cases it is very noticeable, in so far as every sensory impression

which impedes the flight of ideas is immediately elaborated into the
patient's garrulous talk. Thus seeing the doctor's watch chain he
speaks about it, or hearing the jingling of coins he immediately talks
of dollars. This enhanced distractability may also be described as a
disturbance of attention in the form of hypotenacity with hypervigility.
Both subjectively and objectively one gains the impression that the
flighty patients think more rapidly. However, the correctness of this
cannot be demonstrated experimentally. There is no doubt that the
patient spends much less than the normal time on the individual ideas,
which also accounts for the fact that they are insufficiently elaborated.
Thus flighty thinking is not aimless in content, although its aim is
forever changing. It shows a preponderance of external and word
associations at the expense of inner associations, which connect the
ideas according to logical sequence following the actual mental trend
in the form of associations of super-order, sub-order, or causality.^ In
place of inner associations there may
be accidental connections, as
Salami, Italy, instead of the journey to the Righi, which do not even
emanate from the sense of the word but from its sound, as seen in
association types of rhyme and word completions. Thus to the word
"bird" a manic patient answered: "Birds of a feather, flock together."
The following example taken from the production of a patient
showing flight of ideas will serve as ar^ illustration: Question, "Who is
the president of the U.S.?" "I am the president, I am the ex-president

have been a recent president. Just at present I
of the United States, I
was many towns in China, Japan and Europe and
present, president of
Pennsylvania. When you are president you are the head of all, you
are the head of every one of those, you have a big head, you are the
smartest man in the world. I do testory and all scientist of the whole
' One of the main headings in the classification of associations is "Coordina-
tion" which includes associations of co-order, super-order, sub-order, or contrast.

Examples of super-order are "fly," "insect" "water," "ocean." E\amples of

sub-order are "forest," "trees" "animals," primates," etc. (Editor.)
world. The highest court of doctoring, of practicing, I am a titled

lady by birth of royal blood of rose blood (pointing to anotlier
patient) , ho has black blood, yellow blood, he is no man, a woman, a
"
woe-man, etc."
The stimulus word "key" elicited the following: "Oh you can
have all the keys you want, they broke into the store and found peas,
what's the use of keys, policeman, watchman, dogs, dog shows, the
spaniel was the best dog this year, he is Spanish you know, Morro
Castle what a big key they have (refers to a visit in Cuba) Sampson,
Schley, he drowned them all in the bay, gay. New York bay, Broad-
way, the White Way, etc." ^
One can always note a weakness in the patient's reflection and
judgment. Even if they bring to the surface some ingenious thought
and are able to utter truths which would not occur to normal persons
or which they would suppress, such productions are in most cases
extremely superficial in judgment, they are one sided and hasty, and
are deficient in some of the necessary factors. Wherever the choice of
impressions and ideas are inadequate there is also a lack in orderly
arrangement. Whenever one gets the impression that the patient's
achievements are above the average it is usually due to cessation of
inhibition and not to an acceleration of his mental facilities. The

average person cannot say some things, he cannot even think of them,
because of consideration for others or himself or because an inner
critique keeps him back, the flighty patient, however, ignores such
reflections or they never occur to him, he knows no embarrassment.
Sometimes, especially before merging into a depression or into a
manic depressive mixed state, the patients firmly adhere to an apparent
aim but leave out all logical connections. Such persons limit their
productions to a series of names of persons, places, offices, etc., some
individual parts of which besides being linked through the general
superordination of the ideas, are also associated through sound
similarities.
Flight of ideas is an essential component of the manic symptom-
complex. Similar mental disturbances also occur in exhaustion and
perhaps also in toxemias. In all probabilities there are distinctions
between the individual forms, but we do not know them as yet.
Flight of ideas does not represent a simple acceleration of associa-
tions. Liepmann endeavored to explain it on the basis of a disturbance
of attention, but one gains nothing by it as one can just as lief reason
the other way and explain disturbances of attention through flight of
' Givênby editor.
* Given by editor.
ideas. We might venture the following conception: Regulated thinking
is conditioned by the fact that the hierarchy of the leading thoughts
inhibit all ideas not belonging to the theme. As we must also assume
in other cases, the inhibiting resistance obtruding itself is relative in
its action. As intrapsychic functions are only too easily stimulated in
manic patients the patients feel a bubbling over of thoughtsthe
stimulus threshold seems smaller and the relation between inhibition
and function is disarranged. In view of all that, the resistance exerted
by the leading thought no longer suffices to inhibit associations which
are unrelated to it.
Melancholic Retaedation of Associations (Inhibition)

A retardation of the train of thought, already noticeable in sad
normal persons, is present in cases of morbid depressions; the entire
process of thought proceeds slowly and in a laboriously subjective
manner. It is difficult, and often impossible for the patients to change
the idea controlling them; this preferred idea deals with their imag-
inary misfortune (monideism) The patients are frequently aware of
.
their poverty of ideas and perceive it as dreary and monotonous. Ideas

which are incompatible with the depressive thoughts can be touched
upon with difficulty or not at all; so that judgment becomes consider-
ably warped and the development of delusions is made quite easy. On
superficial observation the patients sometimes even give the impression
of feeble-mindedness.
Associations in Organic Psychoses
The number of individual concepts simultaneously available to

patients suffering from organic psychoses is less than in normal; this
can be most readily demonstrated when the patients attempt to do

examples in arithmetic. Whereas normally the patients were able, for
instance, to do mentally an addition of four-digit numbers, they can
now only add one one-digit number to a two-digit number without for-
getting the problem. The characteristic restrictions of organic disturb-
ances is shown by the fact that the selection as well as the rejection of
associations occurs mainly in the sense of the affective trend. Where-
ever it is primarily a question of affects or impulses, the associations
antagonistic to the particular impulse are left out. As examples of
this, one may cite the former morally senile patient, who, in a state
of sexual excitement sees only the female in the child and abuses it
sexually, or the paralytic who
some tempting object under the
steals
eyes of a few dozen spectators and conceals it under his clothing, or
the paretic who jumps out of an upper story window in order to pick
GENERAL PSYCHOPATIIOLOGY 7o
up a fallen cigar-stump (Kraepclin). A senile patient is capable of

praising his mother as a saint and immediately thereafter merge into
another constellation and have nothing but evil to tell about her.
This restriction of thought for the time being to a specific cluster
of ideas physically speaking, is like an attempt to get one's bearings
through a key-hole, exposes the patients to the danger of committing
great stupidities; they enter into business undertakings without con-
sidering risks, they contract foolish marriages, or commit similar
foolish acts.
When only a few ideas can be grasped simultaneously, an orderly
arrangement of them becomes difficult. Thus a patient states that he
was born in 1872, he knows that it is now 1917, but nevertheless thinks
that he was 62 years old ten years ago. He comes to this conclusion
by subtracting 10 from 72 instead of from his present age. The co-
ordinating associations as such may also be affected.^
Furthermore, a restriction of associations may also be due to the
fact that especially senile patients, and less so paralytics and
Korsakoff patients, become more and more egocentric and are par-
ticularly fond of concerning themselves with their own pleasures and
woes, often in a very petty fashion. Nevertheless, they are much
more capable, than, them-
for instance, organic epileptics, of occupying
selves with other things, in so far as they
can still grasp them. They
are especially capable of showing a very affective and exaggerated
interest in the affairs of their friends and enemies. In conversation
the patients find it difficult to pass from one thought to another. Even
in cases where primary comprehension is still quite good, they answer
to a question which does not exactly belong to the particular subject,
frequently they answer only after numerous repetitions, or in the sense
of the former trend of thought. It thus often happens that they still
continue to give information about personal matters when that topic
has long been finished and when the question may refer to their
education.
Besides those mentioned there are other mechanisms which often
prevent the patients from leaving an idea. Thus in an association test
they will repeat again and again an accidental reaction word, and in
a perception test they will call a penholder a cow, if the picture of
such an animal has previously been shown them [perseveration).
The duration
of time of associations in organic patients is retarded
in most This is especially seen in cases of senility, where one
cases.
sees additional accessory processes, which hamper and retard the
psychic processes, such as cerebral pressure and other phenomena that
" Cf. also "Orientation," p. 32.
76 TEXTBOOK OF PSYCJIIATRY
are not yet well understood. Retardation shows itself with especial
regularity in experimental associations; but in such cases difficulty
of comprehension may play a part. Here the associations are emo-
tionally accentuated, very closely related, and contain many lepeti-
tions, partly due to perseveration of ideas, and partly to poverty of
thought. The patient finds it difficult or impossible to restrict the
reaction to a single word.
A diagnosis can frequently be made in a few moments from the
continuous associations showing the garrulous organic type, which
would have been impossible to do before, when nothing characteristic
could be sufficiently emphasized in the description of the case. In
most cases a question of a slow progress of the course of ideas
it is
with a tendency to repetitions. The utterances often express a pro-

nounced affect in its content, which is even more marked by its em-
phasis. Sometimes one hears nothing but wailing or boasting, with
or without a definite theme. It is through the emotional accentuation
rather than through the greater mobility and better intellectual
coherence, that such out-pourings are distinguished from the lamenta-
tions of depressive Schizophrenic cases, whose affective expressions,
even when present, hardly ever conceal a pronounced rigidity. Typical
associations may be seen in the following:
"My dearest Doctor, "I'm all wrong, O God in Heaven have pity
on me. Father in Heaven be compassionate. Dear good Doctor, help
me. Let me out. Heavenly father, please don't forsake me. I'm not
capable of that. Why, I'm quite right in my mind. Will you please
take pity. I can't do anything else, dearest God. No, no, no, I
must go away, do be merciful. Doctor, won't you be merciful?

Jesus Christ, take pity on me. There is something the matter with
every inch of me. My
judgment is wrong. There is nothing else that
is important. Have pity on my sinful self, Doctor, do forgive me
once more."
Experimental associations ^ are very characteristic in the more
pronounced cases; if there is no question of epilepsy, which exhibits
similar peculiarities, the associations alone are often sufficient to make
the diagnosis. All reactions are retarded. The impoverishment of
ideas manifests itself very clearly in reactions that are not far removed
from the test word, and in generalities, thus the stimulus word "green,"
gives the reaction, "It's everywhere; green the green outside." As in
oligophrenic cases, a large number of the reactions consist in
tautologies, definitions, designations of places, and the like. But even
^''
Brunnschweiler, Ueber Assoziationen bei organisch Deraenten. Ziiricher,
Diss. 1912.
these tend readily to be blurred, thus the word "family" is reacted to

with "Something in the house there." Educated patients get around
their poverty of ideas by means of near-by association of words. The
perseveration tendency often strongly preponderates. The affectivity
shows itself in many reactions as in epileptic cases, but with a much
lower valuation, sometimes it evinces itself in just bare interjections:

Righto Oho! righto; or table what-the-dcuce. Complexes show
themselves directly and without repression. Egocentric reactions occur
frequently, and are said to be quite banal, particularly in paralytic
cases, thus, "bad,"

"I don't know of anything bad," and to consist of
reminiscences of former experiences in senile cases, thus: "mountain,"
"I was once at Horgen mountains, from there I had to go home
from the barracks on foot." As has been mentioned, when the disease
has reached a certain stage, organic cases are no longer capable of
answering with a single word, they cannot isolate the concept, they
must tell the whole idea, or the thing which affects them.
The associations of states of organic confusion have not, as yet,
been the subject of sufficient research. But one can often recognize
even in the confusion the described type of the actual disease.
Schizophrenic (Dreamlike) Disturbances of AsoOciation

(Zerfahrenheit of Kraepelin)
Whereas the empirically acquired structures of associations are

not loosened in flight of ideas and impediment of thought as well as
in organic disturbances of associations, their effectiveness is restricted
in schizophrenia. Neither a manic patient, nor a sound person thinks
of modern Italy at the mention of the name of Brutus. But a schizo-
phrenic, by disregarding the component of time connected with the
term, can call the Roman
an "Italian," or he can designate the location
of Egypt and the Congo State," by again ignoring
as "between Assyria
the periods to which each of the states belong, and at the same time
exchanging in a most bizarre manner the most immediately obvious
place designation (say, "the Northeast of Africa") for one altogether
peculiar.
Although the following two productions lack clear objectivity the
theme which happens
patients nevertheless stick almost perfectly to the
to refer to ancient history narrative of the Orient. The individual
associations seem accidental or stimulated through sound or other
factors foreign to a normal person. They differ from flight of ideas
through the fact that a normal person can understand the individual
steps of the latter, whereas many steps that are made in a schizophrenic
train of thought are unintelligible to the normal person, or appear to
be so bizarre, that they would never have entered his mind. The
following examples will serve as illustrations:
"Epaminondas was one who was powerful especially on land and

sea. He was the leader of great fleet manoeuvers and open sea-battles
against Pelopidas, but had been struck on the head, during the second
Punic war, because of the wreck of an armored frigate. He wandered
with ships from Athens to Hain Mamre, took Caledonian grapes and
pomegranates and overcame Bedouins. He besieged the Acropolis with
gun-boats, and caused the Persian crew to be burnt as living torches.

The subsequent pope Gregory VII eh Nero followed his example
and because of him all Athenians, all Roman-Germanic-Celtic races,
towards whom the priests were not favorably disposed, were burned at
the hands of the Druids as an offering to the Sun-god Baal on Corpus-
Christi Day. This is the period of the Stone Age. Spear-points of
Bronze." (Stenographically recorded.)
The Blossom-Time for a Horticulturist

"At the time of the New-Moon Venus stands in the August heavens
of Egypt and with its rays of light illuminates the harbors of commerce,
Suez, Cairo, and Alexandria. In this historically famous city of the
Kalifs, there is situated in the museum of Assyrian monuments from
Macedonia. There plantain flourishes next to maize columns, oats,
clover, and barley, also bananas, figs, lemons, oranges, and olives.
Olive-oil is an Arabian liqueur-sauce, with which Afghans, Moors,
and Moslemites carry on the breeding of ostriches. The Indian plan-
tain is the whiskey of the Parsee and of the Arab. The Parsee or
the Caucasian possesses exactly as much influence over his elephant
as the Moor has over his dromedary. The camel is the sport of the
Jew and the Indian. In India, barley, rice, and sugar-cane, that is,
artichoke, flourish luxuriantly. The Brahmins live in castes on
Beluchistan. The Circassian inhabit Manchuria of China. China
is the Eldorado of Pawnees." ("Letter of a Schizophrenic")
The association is sometimes formed as a result of factors from

without even when there is not the slightest real connection. Thus
the patient explains his violent action on the ground that "the at-
tendant wears a white apron," only because the attendant happens
to be standing near when the question is asked.
Not new ideas crop up which have no connec-
at all infrequently
tion of any kind with what has gone before, sometimes the patient
states that they "flashed" through his mind but at other times he does
not recognize anything abnormal about them. If the last-named
mechanism repeatedly recurs, the mental stream becomes "distorted"

and finally coherence disappears altogether. The individual thoughts
then have no connection with one another from the point of view of
the observer, and in most cases also from that of the patient. Indeed,
it not infrequently happens that the patient never produces any
coherent thought, as the concepts are piled together without any
logical connection. ^^
The separation from experience naturally facilitates
of associations
dereistic thinking in the highest degree, which is actually based on
the very fact that natural connections are ignored. Without the
slightest regard for real and logical possibilities, the faintest wishes
and fears are endowed with the subjective reality of the delusion.
The most usual secondary associations, vague analogies and accidental
connections determine the train of thought. Dereistic thinking is
usually quite unrestricted in dreams because the latter are actively

disbarred from the outer world while in schizophrenia it proceeds at
a mad rate mixed with correct and realistic directives.
In the schizophrenic course of thought one observes the most varied
disturbances. Of particular importance are the obstructions where
the mental stream suddenly ceases remaining away from seconds to
days ('Thought deprivation"). When the obstruction is over, a new
thought, which had no connection with the one preceding obstruction,
frequently crops up.
The distinction between obstruction and inhibition is ver>^ impor-
tant; the latter signifies depression, the former (with the reservation
stated below) Schizophrenia; superficially, however, the two symptoms
resemble very much.
In profound disturbances the reactions to both anomalies are alto-
gether or almost completely reduced to zero. But even when impeded,
patients attempt to answer, the obstructions, particularly in acute
cases, in order to express themselves in motion can usually be over-
come only by strong and persistent effort, and even then the patient
can only produce feeble and slow motions and utter words in a low
tone.^^ In most cases, however, the two kinds of disturbances can
easily be differentiated, inasmuch as impeded patients can react just
as quickly and strongly as sound persons, once the obstruction has
been broken down, whereas inhibited patients always evince the re-
" Cf. below, "Confusion," also the additional details about schizophrenic
thinking in the chapter on "Schizophrenia: Condensations, Displacements, and
Symbols."
"In such cases it is probably not a question of simple obstruction, but rather
of a combination with a third form of retardation of the psychic processes,
which we cannot yet emphasize (swelhng processes of the brain, etc.).
tarded character of their movements. (If the difference does not
manifest itself in spontaneous expressions, the patients can, for in-
twenty as quickly as possible, or to turn

stance, be asked to count to
theirhands quickly one about the other.)
The obstruction may be compared to the closing of a valve in a
piping system carrying a highly mobile fluid, while the inhibition is
analogous to a slowing-up of the flow as the result of increasing
viscosity of the fluid. The obstruction is a sudden stoppage of psychic
processes caused by affective disturbances, and in itself is not a patho-
logical manifestation. Some thoughts and
affects bring to a standstill
actions even normal
in persons ("examination stupor," or "emotional
stupor"). Pronounced obstructions may therefore be observed in all
nervous and particularly in hysterical patients. In those cases, how-
ever, where they are not sufiiciently determined psychologically, where
they become generalized, or last unduly long, their presence justifies
the diagnosis of schizophrenia.
In neuro-physiology, such stoppages of one function through an-
other are designated as "inhibitions" while in psychopathology, the
primary meaning of the word, as the above historical considerations
have shown, is something altogether different, it signifies the general
retardation of thought processes in melancholic conditions. There are,
to be sure, still other general retardations of the psychic processes for
which we have not yet any special designation because we have no
adequate knowledge of them. Many are named in accordance with
their causes, as schizophrenic swelling of the brain, brain pressure in
and brain-torpor. In another
general, toxic, epileptic disturbances,
connection "inhibitions" spoken of in a moral sense, thus a
are
psychosis, or alcohol destroys the inhibitions connected with wrong
actions. Here again the meaning of the expression tends towards its
usual physiological significance.
In superficial contradistinction to obstruction, schizophrenics often
feel a "crowding of thoughts"; they are forced to think. In such
cases the content subjectively seems rich and varied, and gives the
impression of a continuous mental stream. But if the attempt is made
to penetrate a little more deeply, one regularly gets the impression
that the patients are forced to think always the same thoughts. The
crowding of thoughts most cases connected with a disagreeable
is in
feeling of exertion. The feeling of activity may, however, also be
lacking; "something thinks" in the patients, or "some one makes them
thoughts."
Crowding of thoughts is distinguished from obsessive ideas by the
fact that in the former the obsession lies in the subject-matter, while
in the latter, it is in the process. The compulsive patient cannot rid

himself of an apprehension or of an impulse, but in the schizophrenic
it is the thinking function itself which is perceived as an automatism
or compulsion, quite independent of the content, which can be prin-
cipally varied in any way.
Furthermore, the thoughts may run too rapidly, as in the case of
flight of ideas, or they may be inhibited. Such complications naturally
occur regularly whenever manic and melancholic states develop in
schizophrenic soil, which happens quite frequently. In such circum-
stances flight of ideas or depressive inhibition is mingled with the
specific disturbance of the associations. The schizophrenic lack of
concern about the aim of the thought naturally shows in some cases
frequent manifestations which cannot in themselves be distinguished
from flight of ideas. The inhibition occasionally causes the observer
to mistake it for brevity of associations, wnich in most cases belongs
directly to schizophrenia and consists in the fact, that the number of
available concepts diminish and consequently the mental stream is
always equally ready or "brief." ^^

This is seen in important as well as in unimportant trends of ideas.
When the patient is asked to relate a fable which he has read, he is
unable to proceed beyond the next step in the story, unless he is given
an additional prod. When asked to tell about his divorce, he at first
knows nothing except: "I am divorced." "Why are you divorced?"
"She ran away from me." "Why?" "V/e did not get along." "Why."
"Because of a child," etc.
Pathological brevity of associations is to be distinguished from a
similar quality in persons who, for some reason or another, are not
willing to give information.
In schizophrenia we often find a special kind of perseveration,
which, to be sure, we are not yet able to describe as regards its specific
peculiarities, although we must assume from other forms.

that it differs
Accidental psychic processes, thoughts, and actions may become

stereotyped; an idea is repeatedly thought and expressed in all varia-
tions and connections, it is "worked to death." Stereotyped habits
are, above all, formed by emotionally accentuated complexes (see
"stereotypes").
Schizophrenic and dream-like disturbances of association may be
hypothetically traced to the same origin: As sleepand disturbances
of attention deflect the associations from their customary paths, it
may be assumed, that a certain force is necessary to keep associations
in the track laid out by experience. Now it is possible that this force
m; ''CLp 85.
or "control-tension" has also been diminished or hampered in its action
because of the fundamental schizophrenic process.^*
Associations of Oligophrenics
The train of ideas of imbeciles and idiots is restricted. But in

contrast to organic impoverishment of associations, it is not the ob-
jective idea that determines here the choice of the reduced psychic
material. The ideas which are left out are those which are uncom-
mon, and do not originate from the immediate sensory perceptions, or
those which are more complicated and do not belong to every day
experience. The imbecile does not forget that he can get hurt by
jumping out window, but he might have an accident as a
of a high
result of climbing down a trellis-work whose carrying strength he over-
estimates. An imbecile described by Wernicke was driving a wagon
which struck a rock and therefore could go no farther. He thereupon
whipped the horses instead of driving around the rock; the act of
resorting to the whip when the wagon will go no farther is really the
habitual thing to do, while it happens only rarely that there is need
for driving around an obstacle lying in the middle of the street.
Within particularly easy reach and at the same time easily stimulated
are those ideas which concern the ego. That is to say, they belong to
those ideas which are most easily thought of, a fact which gives rise,
in imbeciles, to a sort of egocentricity, which is further strengthened
by the lack of understanding for the matters which concern others.^^
Associations of Epileptics
For obvious reasons (concomitant congenital weakness plus cerebral

atrophy) the associations of epileptics often show disturbances similar
to those of imbeciles and organic cases but in addition, they present
the specific epileptic signs, which are so characteristic that they furnish
the material for diagnosis in cases that are more or less pronounced.
Nevertheless, the line of demarkation from the organic cases is not
yet sufficiently distinct. The abnormities which show themselves most
clearly in the experimental associations are as follows: the answers
come very slowly, the patients find it difficult to respond with a single
word and they frequently employ whole sentences that are often very
indistinct, containing peculiar and tortuous expressions. The content
is poor in ideas showing tautologies, meaningless definitions, and the
" Bleuler, Storung der Assoziationsspannung, ein Elementarsymptom der

Schizophrenien Allgem. Zeitschr. f. Psychiatrie 1918. P. 1.
For more details see the chapter on oligophrenia.
^''
.
like, and contains many affective designations among which one fre-
quently finds opinions of value, such as good, beautiful, just, "one

should," and moral tendencies. Another mechanism observed is
that of perseveration, not so much in the sense that the patient gets
stuck to a reaction, but a word, a phrase or sentence form once used
easily crops up again later on. The entire circle of ideas gradually
becomes more and more completely narrowed down to the patient's
own ego.
Examples: Poverty of ideas manifests itself among other things
in senseless associations, continued grammatical constructions, tautolo-
gies,
and the like; thus, long is not short; loved what one likes is
also loved; heart there are kinds
people; beatpeople; sacrifice all
of wonder to wonder. Egocentric relations: wish health;
sacrifices;
naturally one would rather be well than sick; time would gladly I
spare for the sake of good fortune.
it, Examples of emotional
emphasis and affective valuation: greenish a pretty color; sweet is
is good; to part not beautiful; youth joy; to strike

is persons evil
strike. Clumsy and obscure circumstantial expressions: luckjoy ful-
ness or something that." Wrath man
like wrathful. Flower is ^^
the flower belongs to the trimmings of the window-plants in the dwell-

ings of people, that so?
isn't point one can make a point, what one
^*
does in business, if a stone is made, or something

(wishes to say else ^^
something to the effect "sharp stone")

A type of perseveration also occurs with great frequency in ordi-
nary conversation and shows itself in the fact that patients can hardly
get away from an idea. They repeat themselves word for word or in
tautologies, they use circumstantial modes of expression, they present
a multitude of non-essential trifles and trivialities, but they do not
lose their goal, nor can they be diverted from their snail-like paths
by being requested that they come to the point. Indeed the distract-
ability of epileptics abnormally slight. The circumstantiality of
is
their thinking is sometimes also reflected in their actions and their

entire behavior.
Whereas a sound person will, so to speak, sit down in one con-
tinuous movement, many an epileptic finds it necessary to perform
this act in the following manner: He first places the chair in a special
position, then he considers his spatial relation to the chair, then he
proceeds to place himself in the proper attitude towards the same, and
^^
Fuhrmann, Analyse des Vorstellungsmaterials usw. Diss. Giesen, 1902.
" Ihid.
^^Holzinger, Assoz. Versuche bei Epilepsie. Diss. Eriangen, 1908.
thereupon he must arrange his clothes accordingly, as for example,
he must draw apart his coat-tails, and now at last he can sit down
in a sprawling attitude.
In speech one is frequently struck by a momentary hesitancy or
stalling; in such cases the patients often repeat a syllable several times,
and then they proceed further. This symptom is obviously the ex-
pression of a hesitating train of thought; it is as though there were
resin in a machine, which often brings it to rest for a few moments
and then lets it move again.
The intensity of these symptoms generally runs parallel to the
degree of dementia; although it varies very much even in the same
patients and is especially pronounced after attacks and in twilight
states.
The additional part noticed in twilight states has not yet been
characterized. In some cases the main element shows itself in an
enormous exaggeration of the described peculiarities, in other cases
there seems to be added something new, which has been incorrectly
designated as incoherence.
The Associations of Hysteria
The associations of hysteria are under the pronounced domination

of the affects. Even in the habitual states the experiment shows
irregular, often very high-graded prolonged reaction-times, indeed,
sometimes no answer can be elicited, in content the associations are
superficial and psycho-galvanic phenomena are very high.^*' Actual
affects cloud the logic in hysterical patients to a very high degree.
That which was today praised to heaven may be painted with coal-
black colors tomorrow for just as many opposing reasons. In the
hj'^sterical twilight state reality is systematically side-tracked and an-
other dream-world is created to replace it; this is helped by falsifica-
tions of logic and sensory deceptions.
Associations of Neurasthenics
In the association test remarkable that

with neurasthenics it is
they often answer to the test-word instead of to meaning, they its
behave just like patients who suffer from acute exhaustion. For the
rest their associations have not yet been sufficiently studied and can
just as little be brought into a single purview as the morbid pictures
to which the name is applied.
"That is, there is a diminution of electrical skin-resistance at the appearance

of affects.
Associations of Paranoiacs
These associations in so far as they arc pathological, are purely
katathymic,^' that is to say, they exhibit characteristic abnormalities
only in cases where emotionally accentuated complexes at the basis
of the delusional system are brought into play. Many things are then
brought into incorrect relationship to the delusional system. Thus
one finds an association-readiness for certain definite impressions, de-
lusions of reference, coordination of inappropriate material with the
logic functions, a regardless omission of contradictory matter, and a
false valuation of material used. Wherever the delusions do not in-
terfere, the thinking process appears normal.
Other Disturbances of Association

Besides these disturbances of associations, which are characteristic
for definite illnesses or states, there are many others of which we have
no knowledge; they form the subsoil of delirious, soporific, and many
confused twilight states in fevers, inner and outer toxemias, in different
brain diseases, and the like.
Outside of schizophrenia there are also pathological brevities of the

associations: the patient always gets through with his thoughts quickly,
whether they are his own or those which have been induced from the
outside by means of questions and suggestions. The patient does not
think of related ideas even when they might have to follow of neces-
sity, as in the case of wishing to give an account of something (indeed,
this occurs without the existence of obstructions or melancholic inhibi-

tions). Besides certain dulled states of schizophrenia, such associa-
tions are encountered in organic psychoses, in rare epileptic conditions,
in many light forms of soporific states, and in similar conditions.
A state of monideism may be due to many other causes besides de-
pressive retardation; one observes this phenomenon in all forms of
twilight states, where only one idea systematically dominates the
patient, as for example, to set fire to something, while he has no con-
ceptions of the cause or consequences of the action. The same state
is also seen in deliria following mild cerebral concussions, where any
confused idea accidentally occurring to the patient completely absorbs
him for a long time and from which he cannot be freed even by out-
ward distraction. It is quite clear that in these states, monideism is
something fundamentally different from what it is in inhibitions.

The disturbances previously referred to under brain-pressure,
toxemias, and the like, are not yet fully known.
" See pp. 34-35.
"Confusion"
Confusion is not a unitary disturbance of association in the same
sense as those which have been described thus far, but it is the ex-
pression of quite different anomalies of the mental stream which have

attained a higher grade. It is neither a unitary symptom nor a morbid
picture and can even be produced by disturbances outside of the realm
of the usual concepts of associations.^^
Of the familiar disturbances of association it is naturally the schizo-
phrenics which most readily reach to the point of confusion, because
it is in their very nature to tear thoughts apart. In the acute stages
of schizophrenia it happens that not only the thoughts become con-
fused, but the false connection of theprimary associations to the sense
impressions already leads to illusional disorientation. Nor do the
movements correspond to the thoughts, they may even appear dis-
turbed in their coordination. In the same way paramimic and para-
thymic phenomena become connected with it.
Confusions incident to delirious and twilight states are still quite
insufficiently known.
Occasionally flight of ideas may become intensified to the point
of confusional flight of ideas; it is, however, necessary to guard against
mistaking it for schizophrenic disturbance of associations, complicated
by As every one knows, marked emotional fluctuations
flight of ideas.
in normal and diseased persons lead to affective confusion at some
time or other.
The expressions, incoherence and dissociation, which often designate
confused processes of thought apply most correctly to schizophrenic
disturbances of association, but signify nothing of a characteristic
nature.
DiFFUSENESS AND CIRCUMSTANTIALITY
we have mentioned
In the discussion of the associations in epilepsy
circumstantiality and diffusenessP This symptom occurs also as the
result of other disturbances and in any case has different origins. As
long as the flighty patient can still come back to his main subject, he
may be considered circumstantial, because he works out many details
and secondary material which are not needed. Thus diffuseness is
often the first striking indication of incipient mania. An imbecile

can be circumstantial because he is incapable of distinguishing between
essentialsand non-essentials and hence he must go into unimportant
matters as fully as into main issues. Repetitions and tautologies,
'"See below: "Hallucinatory Confusion."
^ Two not identical concepts, which, however, coincide for the most part.
characteristic of the circumstantial epileptic train of tiiougfit, arc

usually absent in manics and imbeciles. It is well known that senile
patients also become circumstantial, partly because the train of
thought gets into ruts which they are no longer capable of avoid-
ing, and partly particularly, because the substantiality of the affective
tone and the narrowing of the associations making reflection diffi-
cult, makes the nonessentials appear as important as the main

theme. There are perhaps still other unknown reasons for the senile
circumstantiality.
Circumstantiality sometimes originates from a feeling of uncer-
tainty which impels the patient to add all sorts of corrective and sup-
plementary determinants. In this form it may appear in the most
varied states. It is also utilized to put off an unwished for decision.
Overvalued Ideas, Obsessions (Obsessive Acts)

Overvalued Ideas are ideas that always obtrude themselves into
the foreground, they are mostly remembrances of an affectful experi-
ence, but in contrast to autochthonous ideas the patients do not per-
ceive them as strange,and contrasted with compulsive ideas are not
felt as incorrect. They are completely bound up with the personality
and differ from ordinary affective ideas only in the fact that eventually
one does not get rid of them and that they have the tendency to
associate themselves with new experiences. According to Wernicke
they are not delusions in themselves, but through morbid relationships
often give occasion for delusions. They are katathymic ideas, which
according to the current conception appear as the only essential symp-
tom in persons that would otherwise be considered sane. Ziehen, how-
ever, also designates as overvalued ideas, obsessions, and many obtrud-
ing delusions. In positing overvalued ideas the question of the exist-
ence of monomanias, which for nearly a half century appeared settled
in the negative, has once more been taken up, though in a much more
comprehensible form. In the case of an existing predisposition or
without this, is it possible for an outer experience, intensified by an
accidental cause, to provoke delusions in a psyche not really morbid?
I should like to answer in the affirmative. But only when these "over-
valued ideas" become an active influence does one deal with a real
psychosis (compare on the one hand "belief" and on the other
paranoia). 2*
Obsessions or compulsive notions are ideas which continually
obtrude themselves against the patient's will with or without exiernal
" Some designate as monomanias not delusional forms in otherwise retained
but isolated morbid impulses like kleptomania or pyromania.
lucidity,
cause,^^ the content of which, however, is recognized as incorrect except
in states of strong affects. Nevertheless they do not appear strange to
the personality as they are regarded as the product of one's own
thinking. They are remarkably monotonous and may be divided into
four groups: Some people
feel compelled to put definite questions to
themselves, many which are foolishly banal, such as, "Why has a
of
chair four legs?", some deal with insoluble problems about final causes,
such as, "What existed before the creation of the world?", some are
more or less of a religious nature, such as, "Why is God a man?", or
"How is the immaculate conception possible?", and some are of a sexual
content, which are often also plainly an element in those previously
mentioned ("Reasoning mania") Others have anxious ideas that the
.
match has not been put out, or the door isn't locked. They cannot
mail a letter, because in spite of repeated examinations they are not
convinced that it is in the right envelope, or that there isn't a serious
mistake in it. They are afraid to touch a door knob because they
themselves may carry germs to others, or others to them ("delire du
toucher"). If a knife is lying around, they fear they may kill some-
body with it usually
one of their relatives.
Others fear their father may die if a spoon lies on the table in a
particular way, or if one does this or doesn't do that, in which cases
one cannot always tell whether the patients are fully convinced of
the incorrectness of the "superstition." Obsessions that some horrible
crime was committed may merge directly into delusions of sin, which
then also appear most frequently in states of melancholia. The phobias
are also classed with obsessions. Thus one observes an agoraphobia
or fear of open places, erythrophobia or fear of blushing, and similar
ideas which realize the dreaded occurrence (fear of getting diarrhoea
where it is impossible to satisfy this need) this can be brought about
;
through the activity of the smooth muscular system which is not

controlled by the conscious will. Other phobias, like mysophobia, or
fear of dirt and eventually infection, belong to the group of delire du
toucher, and lead indirectly to actions.
Some of the compulsive acts are the result of the compulsive ideas
and cannot therefore be separated from them. Thus the idea that the
door not locked compels the patient to try it over and over again or
is
ask others to examine it. Mysophobia compels one to touch the door
knob only through cloth and to wash the hands continually. The
notion, "If I do not return the money, my father will die," compels one
to return it even under difficult circumstances. Obscene contrast ideas
" They are in this way also disturbances oj the will in so far as the patient
has no power to direct his thoughts to normal thinking.
compel one to utter them (coprolalia). Often the obsession and the
compulsive impulse are identical as in the impulse to kill one's child
with the nearby knife, or the thought presents itself, like a halluci-
nation, in imperative form, "You must kill your child."
A man who has a questionable affair must turn around and look at
every "dark, tall, sturdy" woman, then also at small ones, then at all
women, then also at men, and then at street cars to read their
numbers.
Another kind of association between an obsession and compulsive
impulse was shown by a patient, who was not melancholic; he had the
obsession that he had had intercourse with his mother and the com-
pulsive impulse to write this fact on banknotes.
Connected with the compulsion is a very painful affect; still not all
patients can rouse themselves to the state of really desiring to be cured,

in spite of the fact that a feeling of sickness is perhaps never lacking
The ideas themselves are either of a depressive -^ content, or anxiety
appears as soon as the patient wants to resist the impulse. It is
anxiety that makes it impossible for the patient to suppress the impulse
in spite of the fact that he is willing and knows better. But the
patient has to see repeatedly that the match is out, not so much to
prevent a fire, as to rid himself of his fear, indeed the execution of a
compulsive act may actually be connected with "a peculiar feeling of
voluptuous satisfaction." The fear itself often seems to be (incor-
rectly) the result of the idea (fear of germs) ; at times it accompanies
the idea and more rarely it appears as primary, in which case the obses-
sion may if it were created as an explanation
give the impression as
for the affect. But
probably true that obsessions most frequently
it is
develop on the basis of a timid, uncertain, but conscientiously inclined

and melancholies.
character, also in exhaustions
Freud has attempted to explain obsessions by assuming that any
relatively innocent idea is connected with another which became
repressed on account of its unbearable content. The former then
receives the affective endowment of the idea, which has become un-
conscious, and forces itself into consciousness in place of it. Thus a
girl at a concert feels the impulse to micturate in the course of sexual
thoughts which she rejected as immoral; thereupon at ever>' similar
state of affairs she had a phobia that she might have to micturate.
It is certain that obsessive cleanliness may frequently be traced to
the need for moral purity, as in onanistic pangs of conscience.
Obsessions occur temporarily in neurasthenic and melancholic
states, in schizophrenia, and also as a special, and frequently ver\'
**
At present I doubt whether there are obsessions of a pleasant content.
severe, disease, in people originally disposed to such abnormities (Com-
pulsion Insanity, compulsion neurosis).
Delusions
Errors originate from the facts that similar things are considered
identical (camelia rose; whale
fish), that a simple coincidence is
considered a regular coincidence and consequently taken as a causal

determinant (e.g. the patient became well because a charm was ap-
plied), or that something important is overlooked (the earth is a
plane) or also, that one is deceived by the senses, and hence unusual
relations are judged according to usual relations, e.g., the sun revolves
around the stationary world. Such errors may be corrected by new
experiences which are enlightening to the extent that reason is capable
of evaluating these experiences correctly. Even when a person is too
stupid to comprehend the sphericity of the earth, we do not call his
conception a delusion. Delusions are incorrect ideas created, not by
an accidental insufiiciency of logic, but out of inner need ("Delusional
need," Kraepelin) . There are no other inner needs than the affective.
Delusions, therefore, always follow a definite direction corresponding

to the patient's affects, and in the vast majority of cases cannot be
corrected by new experience or instruction, as long as the condition
which gave origin to them continues.
Delusions, therefore, have their psychological analogy not in error
but in belief. Accordingly the chief delusion is regularly egocentric
and of essential significance for the personality of the patient himself,
^'^
though, of course, the forms of explanatory and secondary delusions
need not directly concern the patient. Contrasted with belief the main
difference lies in the fact that delusions are formed by individuals
from personal need and that they may relate to matterswhich in sane
persons are subject to correction. We see that the difference is not
absolute. Ordinarily when a pious person
we cannot speak of delusions
forms his own opinion of religious matters; but when his innovations
appear altogether too gross, we designate them as "delusions of
religion," although in the forum of pure logic a new prophet might
have as much reality value as the older ones.
Delusions, therefore, originate as a result of affects inasmuch as
what corresponds to the affect is accepted and what is opposed to it
is inhibited to the extent, that it either does not appear at all in this
connection, or it is of insufficient logical force. The melancholic, when
he takes account of his fortune, sees continually all his debts and
difiiculties but cannot balance them with his assets, partly because he
''See below.
considers them worthless or too uncertain, and partly because he

cannot connect them in a logical procedure with the idea of his debts
and therefore cannot utilize them to overcome the idea of indebtedness.
Such is the origin of the delusion of poverty. Not infrer4uently he
comes to the same conclusion by keeping back altogether the ideas
referring to exact sums, and only in a general way considers his debts.
The onanistic schizophrenic fears that his vice will become known.
If he notices that some one looks at him he thinks it is because of
his onanism, the self-evident fact that one is looked at a thousand
times without such cause, cannot be used as a counter-argument.
The delusional affect may be of a general (depressive or manic)
nature, or it may be attached only to a particular idea, to a complex
such as an onanistic pang of conscience. In the latter case katathymic
delusional forms originate. When a person obsessed with a complex
is at the same time suffering from a general depression, a frequent
occurrence in schizophrenia, the katathymic and depressive effects
become connected. If the schizophrenic onanist is melancholic he
thinks that he is rotting because of his vice; if he is manic, he feels
that he is a savior of humanity.
Some of the delusions follow logically from those already existing
and do not require this mechanism. When the patient is convinced
that the physician wants to murder him and after taking medicine he
feels indisposed, then it is a conclusion, based on logical probability,
that the physician has prescribed poison (secondary delusion). Or
the patient is the son of a count, consequently, his parents are only
foster parents. Or the patient is pursued everywhere, no matter where
he journeys; "therefore there exists an entire organization against him,
the postal authorities open his letters and tell his address" (Explana-
tory Delusions).
It is said that delusions are logically deduced from the affective
disturbance. Thus the patient feels unhappy, seeks a cause and finds
it in his sins. I have never been able to observe this mechanism.
Other delusions are said to originate in hallucinations, deceptions
of memory, and in dreams. This is undoubtedly a question of con-
comitant circumstances, not of real causes. It is the false idea which
is directly generated by the disease; it may appear first as a thought,
or hallucination, or memory deception, or as a dream conception.

Some delusions, especially in schizophrenia, suddenly appear in
consciousness as finished products [delire d'emblee, primordial de-
lusion) ;
^^ others have a longer period of incubation. For instance,
*"! the patient takes a critical attitude toward the content of the idea, it is
called an autochthonous idea {Wernicke).
if they were watched, as if they had sinned, until
the patients feel as
at last becomes a certainty. Or for years the patients make a
it
number of remarkable observations (self-references) and it suddenly

comes to them "as a revelation" that it all has this and that meaning.
Perhaps most frequently the delusion connects itself with external
events in such a manner that the patients at first quite correctly grasp,
e.g., a sermon, but later on, following a period of incubation of from
hours to years, they interpret the words heard, consciously or uncon-
sciously, in the sense of the delusion as related to themselves, that is,
to their complexes.
The following classes are differentiated according to content:
Expansive forms of delusion; "Delusions of grandeur." In the
mildest cases they rather take the form of overestimation of the ego,
the patient surpasses other people in health, ability, beauty to an
extent greater than the corresponding reality. From this we observe
all stages of real delusions, from the easily possible to what is still
conceivable up to the idea that the patient is capable of the most
impossible discoveries, to possess "trillions," to found new religions,
to be God and Super-God. Occasionally the environment is trans-
formed to accord with the idea. The patient's companions in the
asylum are mistaken for counts and potentates.
Depressive delusions refer especially to three spheres: to conscience,
as delusions of sin; to health, as delusions of disease, and to fortune,
as delusions of poverty.
The patient entertaining delusions of sin believes without reason to
have committed the worst transgressions or magnifies actual trivial
deeds into unpardonable sins. For these not only the patient is
punished in an appalling manner here and in the life beyond, but
also all his relatives, even the whole world.
The patient having depressive delusions of sin ^^ believes that he
has definite, and always especially awful diseases. The real disease,
melancholic depression, is denied. The same is sometimes designated
as hypochondriacal delusions; but we must be able to differentiate
between this delusion of general depression and the katathymic delu-
sion that stands out in the hypochondriacal morbid picture especially
in dementia praecox, but also in psychopathic patients.
Usually the difference consists also in the fact that the depressive
delusion of disease postpones the worst for the future, while the kata-
thymic hypochondriac worries about the present. The depressive
patient believes he suffers from closure of the intestines and will perish
" Not identical with the usually katathymic hypochondriacal delusions of
disease.
in a particularly disgusting way, while the hypochondriac asserts that

he actually suffers from intestinal inactivity and demands and expects
relief.
Impoverishment is often thought of in forms which cannot occur,

at any rate nowadays; not only is the patient punished for his debts
and must starve, but his relatives also meet with the same fate.
In demented organic patients we see a fourth group of depressive
delusions which, though not very common, furnishes the diagnosis when
it is present,^" viz., nihilism, which roughly corresponds to the delire
de negation emphasized by the French, or delusions of negation, which

are not to be mistaken for the negativistic manifestations. In this
case everything no longer exists, the institution, the world, the
Almighty, and the patients themselves; they have not eaten, yet they
have not fasted; they have no name, are not men, women, etc. Also
in the delire d'enormite, which occurs under similar circumstances and
is frequently connected with nihilism, the same nonsense finds expres-
sion: The patients may not use a chamber because they would flood
the entire institution or the whole world; they are swollen up so big
that they fill up the entire house and city, and choke everybody they ;
must swallow everyone in the institution and there are so many of

them. In a certain sense the opposite of this is micromania, which
also only occurs in organic depressions. It consists in the fact that
the patients believe themselves to be physically very small; thus a
senile scholar was afraid of chickens because he believed his head was
so small that it might be pecked off.
Depressive delusion may in rare cases be combined with a kind of

megalomania in melancholies, who are not satisfied to be the worst
person that ever existed and ever will exist, but attain the rank of
the head of the devils. This is also found in schizophrenics where
different kinds of affects appear together and express these in parallel
delusions, such as, they are the Mother God and
same time
of at the
the devil, or in a condensation such they are Queen of the Night.
as,
Delusions of persecution do not belong to the depressive forms of
delusion. The delusion of deserved punishment must not be classed
with that of the unjust persecution. The former comes from a general
depression, the delusion of persecution is a katathymic symptom, which
grows from a single emotionally toned idea. Every depressive delusion
is a symptom of a potentially transient condition, but the delusion of
persecution mostly belongs to chronic diseases. An affective, not kata-

thymic delusion of persecution is the delusion of anxiety seen in hal-
**
At the most it can be said that something similar is seen in schizophrenia
but it is not identical.
lucinatory conditions such as dreams, delirium tremens, epilepsy, and
schizophrenia.
The real delusion of persecution may at first be quite indefinite;
the patients feel that things and people about them have become
uncanny ("the walls in my own home wanted to devour me") . Then
they make the discovery that certain persons make signs to them or
to others which refer to them. One coughs in order to indicate that
here comes the onanist, or the murderer of girls. There are articles
in the papers with all too plain allusions to them; in business they are
badly treated, the attempt is made to get rid of them through dis-
gusting treatment, the most difficult work is assigned to them and
they are behind their backs. Finally there are entire
slandered
organizations, created for "this very purpose, the "Black Jews," as well
as the "Free-Masons," "Jesuits" and "socialists" which everywhere
pursue the patient, and make him powerless. They plague him even
with voices, physical influences, and other hallucinations as well as
with withdrawal of his thought, crowding of thought and other
annoyances. Not so seldom the delusion of persecution is combined
with grandiose ideas. A certain overestimation of self generally lies
at the bottom of it, insofar as the patient makes some kind of unattain-
able demands and then looks for the cause of his failure in the environ-
ment. It is also said 'that the delusion of grandeur originates in the
delusion of persecution through the fact that the patient says to himself
that a person who is much persecution must be some
subjected to so
extraordinary person. This transformation of the delusion I have
never plainly observed. On the other hand, we frequently see that
erotic delusions turn into delusions of persecution or fuse with them,
in that the imagined affectionate lover commits sexual and finally other
atrocities on the beloved.
An erotic form of delusions of persecution is the delusion of jealousy
which exhibits several peculiarities. There are paranoiacs who have
no other delusions in schizophrenia it is not seldom mingled with other
;
ideas of persecution, and in alcoholism and cocainism it usually appears

as a temporary result of the poison which is not yet fully explained.
The delusion of reference, or the morbid reference to oneself, has
been distinguished as a special form of delusion. It occurs especially
in paranoiacs and paranoid forms, in which it often forms the base of
the other delusions. Such patients can relate to themselves absolutely
indifferent observations such as coughing, newspaper advertisements,
and even cosmic occurrences they think that everything occurs on their
;
account and interpret it in the sense of their katathymic mental trend.

Something similar also occurs in general emotional depressions. Melan-
cholics especially like to believe that any misfortune is the result of

their badness.
Thus one improbable things, -to test the patient's intelligence.
tells
In the newspaper says that some one fell downstairs in order to make
it
the patient understand that she doesn't clean the stairs properly
Some one yawns; that is to say that she is lazy.
The is explained by the emotional effects with-
delusion of reference
out anything further.^^ Every affective idea has even in normal per-
sons many attachments that do not correspond to reality. It is known
that any one coming into a ball room or wearing a uniform for the first
time, believes himself noticed, etc.
It has been maintained that delusions are a sign of mental weakness^
since a normal intelligence would see the incongruity. But it is certain
that there are very capable paranoiacs evincing a complete delusional
system, who exhibit no other signs of intellectual disturbance. If one
bases here the assumption of mental weakness solely on the delusions,
one begs the question. The essential factor in the formation of a
delusion is the disproportion between affect and logical strength which
may have originated in the preponderance of a general mood, as for
example in melancholia, or in an especially strong affective coloring of
a single idea as, for example, in katathymic delusional formations, or in
the weakness of the logical capacity as, for example, in paranoid and
twilight state, or in several of these forces acting together, as, for
example, in manic paresis.
This formulation naturally indicates only one comprehensible con-
have not yet been
dition of delusional formations out of the others that
ascertained. There are many disproportions between intelligence and
affectivity that do not lead to delusions, e.g., the oligophrenias. The
type of affectivity, the transformation of the entire psyche in asso-
ciating, perceiving, and feeling, as is shown by the schizophrenic
process, and in strongly exaggerated form by conditions of clouded
consciousness, are other important foundations of delusions.
A connection between intelligence and delusions exists in so far that
in mentally clear patients the quality of the delusion depends on the
grade of intelligence. Intelligent paranoiacs ''systematize" their delu-
sions, mixed with real facts they bring them into a system that is
usually logically connected, but which Tias a flaw especially in the

assumptions based on false references to themselves, and on memory
illusions and here and there in its causal connection. The content in
itself is usually conceivable ta others, so that paranoiacs sometimes
infect even intelligent, healthy persons.
'*' Gf. association readiness, p. 40, and attention, p. 41.
Similarly formed ideas in schizophrenia have a far weaker or no
logical connection and in themselves readily merge into the absurd.
Thus the patient was present at Christ's crucifixion; he has made all
inventions, even those used before his birth, the bones are taken from
his body, several times he has been killed and restored to life, and
similar absurdities.
The disturbance of intelligence and unclear thinking express them-
selves in senseless delusions in manic and depressive conditions of
organic patients.
The grandiose manic depressive patient are usually
ideas of the
only overestimations. He is him up,
cleverer than all those that lock
he strikes down a dozen keepers, he will expand his business, he will
yet become a member of the cabinet. In manic forms of paresis the
delusion usually merges at once into the absurd; the patient has large
armies at his disposal which will destroythe institution and the country
in which he is; he is a general although he has never been in service;
he has invented a bicycle with which you can go around the yorld,
over seas and mountains in three minutes; he is the super-God; the
female patient is the mother of everybody, every hour the Almighty
takes hundreds of children from her body, etc.
The melancholic has committed grave sins, for which tortures will
be inflicted on him as on no one else, he suffers from incurable diseases.
But the depressive senile has his brain hanging down over his head,
his intestines have been replaced by a snake, his head is made of wood.
There develop micromania, nihilistic ideas, and the delire d'enormite.
In any case one must be careful in diagnosing weakness of intelli-
gence from the senseless content of the delusions. What has been said
holds without any reservation only for conditions, in which mental
clearness is not entirely absent. In twilight states, in toxemias, in
fevers absurd delusions may appear even in patients who are not
demented, just as in dreams of healthy persons.
Occasionally a delusion that originated in a condition of disturbed
mental capacity as in a dream or epileptic delirium and which is there-
fore senseless, cannot later be corrected, although the intelligence does
not now appear badly impaired. Such a residual delusion may, there-
fore, be senseless without there being at the same time a correspondingly
severe disturbance of intelligence.
The course of delusions is The simple affective and
quite varied.
delirious delusional forms fluctuate and naturally disappear with the
condition which gave origin to them. The katathymic delusions which
were not generated by an exceptional condition, are "fixed ideas" in
paranoia and somewhat less regularly in schizophrenia, which are
changed little even in decades and hardly ever disappear. Even the
seemingly corrected delusions in schizophrenia should rather be con-
sidered as forgotten or pushed aside; their persistence may be shown
too often, especially in corresponding affective reactions. Besides
these, one observes everywhere delusions of diverse origin, which
suddenly appear and rapidly disappear.
The relation of the delusions to the ego is usually very close. The
affect upon which it is based or the ideas themselves usually compel
an excessive, often quite monideistic preoccupation with it. A real
attempt was made to poison a paranoiac who was always complaining
in an annoying way of poisoning. The experience was not connected
at all with the delusion and left him entirely indifferent. But in schizo-
phrenics the affective disturbance and the splitting of the psyche,
especially in the later stages, bring it about, as a rule, that the ideas
leave the patient more or less indifferent, or that they become separated
from the everyday ego, which concerns itself with the necessities of
ordinary existence, and form a world of their own.
4. DISTURBANCES OF MEMORY
Hyperf unction of memory, or hypermnesia, may probably only be
ascertained through the fact that occasionally recollections are much
more vivid and distinct than at other times, that they deal with details
that are ordinarily not noticed, and that they reach back to periods
that are not otherwise remembered. Thus in a feverish disease, in
deliria of senility, a memory series of early youth, even of earliest
childhood may turn up. In a hypnotic state one can at times recall
complicated details as distinctly as if one again saw the things in front
of him. In a dream, also, details, that cannot be reproduced at all in

waking may turn up with the clearness of a sense impression.
state,
In rare cases of schizophrenia, memory pictures obtrude themselves
in the patient in a disagreeable way, in which case they are usually
but slightly connected.
Much more important are the hypo functions. Theoretically, one
may differentiate those of formation, of retention, and those of the
ekphoria of the engrams. In reality, however, the disturbances rarely
concern only the one or the other function, and above all we have by
no means progressed so far as to comprehend really all possible differ-
ences referring to the partial function chiefly involved. A disturbance
of attention, at the time of impression, may harm the recollection in
about the same way as when occurring at the time of reproduction.
I can hardly conceive of a qualitative disturbance of the engraphic
effect, and in the entire pathology I have found nothing that would
indicate its existence. On the other hand, in senile atrophy of the
brain the engraphic effect of the experiences on the psyche is possibly
weakened, and as a result, the extensive effect must probably be
reduced also, for the diffuse extension of the influence in the brain,
which is to be assumed for numerous reasons, diminishes, and fewer
associational connections are formed. One can also conceive that the
hypothetical elaboration of the engrams is reduced in some way, but
is not yet subject to any disturbance that would indicate the fact.
From we know that it certainly
the process of remembering (ekphoria)
participates in many anomalies of memory, indeed there is nothing
that stands in the way of assuming that disturbances of it alone can
explain most memory defects. Recollection generally is disturbed,
when an affect causes a diffuse blocking of thoughts as in the case of
examination stupor. Individually it is difficult to remember that which
is incompatible with an affect connected with self-love which strives
to manifest itself. Transformations of a memory occur whenever there

is an affective necessity, which also determines the direction of the
falsification.^^
To judge the unfortunate concepts "impressibility" (Merkfahig-
keit) is not very easy in pathology. What is considered under this
term is in reality a very complicated function which may be disturbed,
without changing the engraphy or the memory functions in general.
This happens when for any reason what should be noticed is not
properly perceived or else not further elaborated, as in diseases of the
sense organs, in all forms of disturbances of attention, and in reference
to more complicated matters in various forms of dementia where things
perceived are not comprehended. is no lack
In the latter case there
of actual engrams no associative
of the sense perceptions, but there are
connections to assist in bringing them to memory. As the most striking
hypofunction of impressibility is that which is described in the organic
psychoses. Thus in extreme cases every experience, even the most
important, is at once forgotten; a senile woman may be told her hus-
band has died and she will react with tears, but a moment later she
knows nothing about it, and this experiment may be repeated as often
as desired. To be sure, in the defective brain the formation of the
engrams may be somehow impeded, but this is certainly not the essen-
tial factor, because the organic disturbances of memory do not confine
themselves only to the period of the disease and are in no way pro-
portional to the condition at the time of impression, but much rather
to the state existing at the time of the recollection. Furthermore, in not
^ For organic disturbances of ekphoria see below.
very extreme cases most things are "noticed," notwithstanding, but only
for a short time are they capable of ekphorization. One also observes
in every patient memory islands, so to say, as shown in the fact that
some experience is never forgotten or that a recollection, that did not
seem to be there, suddenly turns up in a certain connection. Besides,
the "economy" in time, which is observed in releaming of material
apparently completely forgotten, proves the persistence of a mnemonic
after-effect, even in severe cases of Korsakoff's disease.
Hence, in organic hypomnesias one deals with a disturbance of
memory that involves the more recent experiences disproportionately
stronger than those lying further back, even though what is experienced
during the disease is for various reasons often particularly poorly
remembered. Only this formulation covers all the facts. The main
disturbance is probably in the ability to recall, although the organic
reduction of the associations hinders, on the one hand, the formation
of paths, along which the recollections can be afterwards ekphorized,
and, on the other hand, impedes the use of these paths in the process
of ekphoria. In the same way a senile disturbance of attention not
only impedes the formation of engrams capable of recollection but
also their revival.
Disturbances of the retention of the engrams are not significant in
psychiatry. In view of the large number of chance tests which demon-
strate to us not only the unlimited continuation of the engrams but
their positive consolidation through age, I cannot believe that there is
such a thing as a normal weakening, in the sense, that all memory

pictures become "weaker" with time and finally disappear entirely, thus
producing a pathological exaggeration of such a process. Nevertheless,
organic disturbances of memory are considered from this viewpoint
and justly so inasmuch as the general reduction of their carriers must
naturally impair the engrams in some way but
; the connection of these
changes with the clinical manifestations is certainly very complicated.
It is chiefly the ekphoria that proves disturbed, not the preservation
of the engrams. The disturbance of acute and chronic alcoholism
could also be connected with the change of the engrams. where the
recollections are rather readily brought up but are inexact or wrong,
while the patient believes he is reproducing well. But here, too, other
explanations are more probable.
In coarse brain lesions it seems that definite groups of memory
pictures may become affected, such as certain speech, or motor, or
acoustic, or optical memory pictures. But the extraordinarily indefinite
and fluctuating border of such defects makes it probable, that even
psychic structures apparently so elementarj', are never totally de-
Btroyed; that they are therefore localized in the entire cortex, even
though their most important part, their focus, is concentrated in a
definite region of the brain. If the focus is destroyed then the engrams
can only be ekphorized exceptionally and imi)erfectly, while destruction

of other parts of the cortex affects them little or in a manner hardly
noticeable.
Besides the organic memory disturbances there are also various
diffuse, unsystematized forms of memory weakness. They show
nothing that is uniform and at the present have no great significance in
psychopathology the main thing is not to confuse them with other
;
disturbances. In the anamneses of schizophrenics we very frequently

find the remark that they have become "forgetful," that they no longer
"had any memory." If such testimony of relatives were taken literally,
one would have to conclude that one dealt with an organic mental dis-
turbance because a real weakness of memory does not occur in schizo-
phrenia. On the other hand, schizophrenics readily become indifferent,
inattentive, distracted, and inhibited in their associations, all of which
can bring about that they do not recall things at the desired time.
it
Neurotics, too, have a very freakish memory for similar reasons.

Onanists often complain of a bad memory, partly as a result of sug-
gestion through certain books, and partly perhaps as a result of lack
of concentration, which is determined by the distraction caused through
the complex. In epileptics the memory as a rule becomes weakened
when they already have a marked atrophy of the brain, naturally also
in the organic sense; but this peculiarity is usually concealed by a
general weakness of memory which manifests itself now here and now
there but in which emotionally colored events can be retained more
readily and reproduced in a stereotyped way.
Circumscribed memory gaps are designated as amnesias; the cir-
cumscription may be confined to content (systematized) or to time.
The former occurs in gross brain lesions in such a way that all optical
or all acoustic memory pictures disappear, or only those of substantives
or those of numerals, etc. Naturally, here, too, it is not known what
part of it is due to the memory pictures and what is merely a difl5culty
in ekphorization; at all events, the latter plays a big part as may be
seen from the reconstruction of such amnesias.
In psychoses one meets with amnesias for definite events (kata-
thymic amnesias) During the experience the patient was in an ordi-
.
nary condition of consciousness and reproduced in a normal way all

other events that occurred about that time. Thus an hysteric suddenly
forgot everything that related to her physician Janet, and mistook hfra
for a new assistant physician. In schizophrenia acts of the individual
;
and of others are "forgotten" every day, when the memory of the same
does not just suit the patient. A mild schizophrenic of Wernicke swore
in all good faith, nevertheless falsely, that he had not insulted a police-
man (katathymic amnesia). In such cases one can usually easily
demonstrate in a round-about way
in hysterics most readily by hyp-
nosis that the engrams concerned have not been destroyed, since the
recollection may again appear in another connection.
In some cases the necessity exists to omit an entire period of time,
woman who wished to forget her husband
as in the case of the hysterical
and who then recalled things only up to the time of her acquaintance
with her husband. Thus originates apparently a temporal circum-
scription of the amnesia but in which, nevertheless, the content is the
essential factor and which furthermore differs from the ordinary
temporal amnesias in the fact that it relates to a period of normal
experience.
The rarer negative hallucinations of memory are a little different.
Thu a patient, like all the others, has received his cigars for Christmas
he smoked them up quickly and then began to scold because cigars
were given to all patients except to him. The distinction between this
and katathymic amnesia lies in the hallucinatory obtrusiveness of such
manifestations. Wernicke's patient did not remember something that
he experienced, while upon the other the recollection forces itself that
something that should have happened did not happen. The latter feel
the gap in what should have happened, while the others are not
conscious of any gap.
The most frequent kind of amnesia is the one that follows disturb-
ances of consciousness of all kinds, especially twilight states and deliria.
A patient wakes up suddenly after some sort of behavior otherwise not
in keeping with his character, he does not know at all where he is,
how he got there and what has happened. He recalls things, up to a

certain moment, and then recollection ceases, somewhat as in a normal
person after a "dreamless" sleep. As a rule every point of contact for
estimating the transpired time is lacking; if the twilight state has lasted
several days, the patient usually does not feel the lack of temporal
orientation at all, or perceives it insufficiently. As a rule he under-
estimates the duration of the condition, and thinks it is the day fol-
lowing the one last remembered, as after an ordinary" night's rest.
Amnesias are also not uncommon after purely affective explosions in
psychopathic or in really insane patients. This is seen in outbursts of
prisoners, in depressive and schizophrenic excitements, and similar
states.
The amnesia is not necessarily complete. There are all transitions
102 TEXTBOOK OF PSYTCHIATRY
from absolutely no memory up to complete recollection, just as in the
recall of our dreams. This amnesia also resembles that following the
dream, insofar as it may be variable. Frequently, immediately after
waking some things can be remembered that are forgotten some time
later, and, just the reverse, an initial total absence of memory may
clear up in the course of the next hours or weeks, especially when the
patient is reminded of his acts. As in every case where there is a
certain weakness of memory, a selection of the retained memories may
take place even in quite harmless cases, which is an exaggeration of
normal states, inasmuch as only what is unpleasant to the patient is
altogether or mostly forgotten. The knowledge of these incomplete
amnesias is very important because criminal acts are not seldom com-
mitted in twilight states and in case the patient shows a wavering
recollection, the judge is inclined to take simulation for granted.
Also the exact time of the beginning and ending of the amnesia
cannot always be definitely fixed, which may lead to new difficulties.
In part, but not at all invariably, such a manifestation is connected
with the course of the twilight state, in which clearer moments may
change off with those entirely unclear.
The amnesia may also extend beyond the time of the abnormal
state, taking by preference a backward direction; this is designated as
retrograde amnesia. This is very often the case after dreamlike or
unconscious states in consequence of head traumas or after attempts
at hanging. The patients no longer know at all that they got into the
situation that produced the trauma arid how they got there. Antero-
grade amnesia ^^ occurs much more seldom and perhaps only during a
gradual transition to lucidity which deceives the observer as to the
severity of the condition. Here there is a prolonging of the amnesia
to the time immediately following the attack, which period may last
for hours or days.
During the twilight state one usually can easily ascertain that the
patient can recall events experienced in the same attack. One of our
epileptics, whose twilight states often lasted several weeks, pretty regu-
larly recalled during these attacks the occurrences of the last two days;
but from this period the amnesia followed continually the course of
time. Moreover, the memories may turn up again in the next analogous
Ûnfortunately this term is also used for various other disturbances of

memory, as for a condition in which every experience is at once forgotten, as
in our organic memory disturbance, without a consideration as to whether the
disturbance of recollection also extends to former experiences. It is also used
in cases like those of the epileptic, in the following paragraph, with whom the
anterior border of the amnesia followed the present time by an interval of
two days.
:
state; this is seen not only in hypnotic and hysterical twilight states,
but also in epileptic and even toxic states. A drunkard, who in a

drunken condition has mislaid his keys, knows the next time he is
drunk where they are, etc. Also in the hypnotic as well as in epileptic
statesmany such twilight states may be brought to light again.
In the conditions that lead to amnesias we regularly have a
markedly changed mental activity. In the hysterical states and in
attacks of rage and anxiety it is the emotional effect that produces a
different relation, in alcoholic intoxication and in epileptics it is the
poisoning of the brain, while in organic cases it is, doubtless, chiefly a

metabolic disturbance in consequence of circulatory changes, particu-
larly through vascular occlusions and cerebral pressure. Under such
circumstances apperception is already inadequate and still more the
elaboration of things perceived, that is, there is an inadequacy in the
connection of normal associations with the individual's existing sum

of ideas with the help of which memories are ordinarily aroused. All
of these are additional impediments to the capacity to recall. Even
a normal person could not recall the disorderly confusion that many
states of dimmed consciousness present.
But the most important factor, which is nearly always present, is
probably the entirely different state, namely, the combination of ideas
changed as to content and form. Even the health}^ person does not
possess full control over his memory resources if he wants to make
use of them under unusual circumstances or when he is preoccupied.
It cannot therefore cause surprise if similar phenomena occur wherever
there was a change in the usual state of the association. If one no
longer remembers the events of a particular place, they often come
plainly into consciousness as soon as the place is revisited; after a
manic depressive attack recollections are often dimmed, but in the next
attack, even if decades have since passed, they may readily obtrude
themselves with most unusual clearness. We have good reason to
suppose that the amnesia for the first period of childhood may be
attributed to the powerful transformation that the personality has to
undergo in this period. That the suckling has no memory- is naturally
a senseless assumption.
The essential factor in many hysterical amnesias is the e.vclusion
of an unpleasant recollection {or actual fact) from consciousness.
This necessity has usually already provoked the twulight state. To
illustrate
Through clumsy manipulation behind her husband's back, a woman
has made inroads upon his fortune, on account of w^hich her husband
wanted to leave her. She now merged into a twilight state from which
she had excluded a large part of time of her married existence and
especially the birth of a child which occurred when her troubles began
and made the situation more difficult; she could not be brought to
herself through explanations. After a while she became more lucid,
but only after her husband had become reconciled to her was she able
to recall her guilt and the marital difficulties; but she could not recall
the twilight state.
The inability to recall frequently does not lie in the condition at
the time of the experience, but in an actual resistance to the ideas
about to be reproduced. Even in the case of experiences occurring in
clouded states only those that are unpleasantly accentuated are some-
times conspicuous.
Thus an epileptic teacher who had stolen during a twilight state,
afterwardsknew nothing either of the thefts or of the epileptic attacks,
which he had while under observation in an institution, although he
had not only been led over both episodes but was also convinced of
them; at the same time he remembered well most of the details of_his
flight to a foreign country.
As disturbances of ekphoria we have still to mention the schizo-
phrenic states in which obstructions, abnormal mental trends, and in-
coherence prevent the finding of the usual paths. In this connection
it should also be mentioned that where few associations are present,
as in organic casesand in imbeciles, recollection may start from fewer
under certain circumstances, proceeds less readily.
points, and, therefore,
Recognition has naturally become impossible where recollection in
general has ceased. Senile patients often do not recognize their nearest
relatives. But recognition is retained much longer than simple recol-
lection, for the association of a new impression with a memory picture
of the same thing is certainly one of the strongest impressions, and
very easy to find. Thus we also see in examining the impressibility
that, although the patient is unable to repeat a name just previously
mentioned, he can, without difficulty, select it from a number of words
presented to him.
The alteration of the feeling tone and other regularly occurring
subjective additions of a perception which have not yet been described,
can under conditions so change the latter, that the object appears
strange to us and in rare cases is not recognized. Neuropaths and
melancholies very often feel that everything seems strange to them,
but only seldom do they consider the things really changed, in schizo-
phrenics, however, the reverse is often the case.
As parafunctions of memory (memory deceptions) we recognize,
in the first place, the inaccurate recollections. They are found, as
GENERAL PSYCHOPATHOLOGY lOo
mentioned above, in acute and in chronic alcoholism, but especially

in organic cases and also in epileptics. In the latter similar memories
can easily be mistaken for each other when such a patient, for example,
was twice in prison, the two events merge together, especially when he
is in a twilight state. He then relates about a time spent in prison
which belongs to the other episode, and what is even more character-
istic of epilepsy is the fact that he cannot get away from the idea of
the repetition, and under conditions he will continue to relate how
he was discharged from prison, then worked, then came into prison,
and then he was again discharged and again locked up, etc. Indistinct
and inaccurate memories are also common among those imbeciles who
in their concept formations do not firmly adhere to sensory perceptions,
whereas in the others we can often find a remarkably faithful repro-
duction of experiences.
On the whole, these inaccuracies of memory receive little attention
in pathology. More important are the systematic memory falsifica-
tions which are designated as illusions and hallucinations of memory.

The memory (paramnesias) are exaggerations to the
illusions of
point of pathology, of memory disturbances which are so frecjuently
provoked through affects in healthy persons. They play a great part
in all forms of insanity, but the greatest part is played in paranoia
and schizophrenia. There is no paranoiac who does not change his
memories in the sense of his delusions, but just here one can some-
times verify how the original memory pictures as such have not
been changed; the patient affirms, for example, "that the pastor had
preached about me. He said that I am now looked upon as an
insane person and I am not good for anything else." On intensive
questioning one at first receives, despite all urging, the verbal quo-
tations of the pastor's speech in the form mentioned. But if the
doctor and the patient do not lose patience, one can finally show that
the pastor said: "Happy are those who are poor in spirit," but that the
patient referred to herself the words in the given sense and translated
this sense in words which she put in the pastor's mouth without realiz-
ing it. In the delusion of princely lineage a visit paid to the parents,
which perhaps insignificant, is translated by the patient as
in itself is
a visit from a minister.Here, too, one can often elicit through patient
questioning of the patient that one does not deal with anything
important. In both these cases, however, the patients are not any more
convinced by these analyses, and immediately thereafter repeat their
assertions in the original form.
Melancholies entertaining delusions of sin are in the habit of
investigating their whole life for faults that they may have committed.
They not only make a deadly sin out of such trivialities as stealing
apples in childhood but they also often change the content of the
memory in the same sense. In their excitement manic patients easily
get into friction with their environment. They are regularly the
aggressors and put the others on the defense. Even during the course
of the illness, but more remarkably also, even after the attack, they
recount these experiences for the most part in an entirely different
light, they represent themselves as the ones who were maltreated, mis-
understood and unjustly attacked. As they are now quite calm and,
as a rule, quite sensible, it is difficult not to believe them if one is not
himself well acquainted with the situation. At all events we know
that patients suffering also from other mental disturbance, above all,
the clearer minded and litigious schizophrenics, behave in the same

manner in similar situations.
A systematic memory disturbance which is also determined by the
affect is at the basis of the alternating personality.^^
Memory illusions which connect the experiences of others with
one's own person (as in the case of appersonation), merit special con-
sideration. Schizophrenics sometimes aver that they experienced
things which really happened, but not to them, but to their nearby
patients. Whoever
considers himself Christ, believes that he had been
crucified, and, under certain conditions, can delude himself into remem-
bering the details of it with perceptible acuteness; to be sure, the
greatest part of such products become unclear in consequence of the
imperfection of the sensible components and are thus recognized as
incorrect.
Parallel with the memory we may put those memory
illusions,
deceptions which freely create amemory picture, which has no con-
nection with a real experience, that is, the memory hallucinations
which endow a phantasy with reality. The latter must be taken in
the strict sense as confabulations, for they really also deserve this
name. Objectively they represent ideas having a timbre of something
experienced or of something remembered.
Memory hallucinations appear almost exclusively in schizophrenics.
All of a sudden memories appear which have no basis in experience.
The patient immediately begins to be abusive saying that last night
he was taken into the tower and made to go through all sorts of
gymnastic tricks, in order to throw him finally into the river. The
following days the story is continued and constantly becomes more
complicated but is seemingly arranged after a definite plan. He is
finally made to fly (before aviation came into existence) and goes
" Cf. below under Disturbance of Personality.
through the whole world. At the same time it is surely not a cjucHtion
of verifieddreams or of hallucinations of the senses, for many of these
experiences are put back to a period when the patient was C4uitc
normally occupied with work or singing. In other cases the memory
hallucinations are less systematized and consist only of fragmentary
details. The normal person can
easily read himself into this ab-
normity, he thoroughly observes his dreams. A great part of the
if
experiences which are later put into the actual dream, are in reality
memory hallucinations and immediately come up in the associations as
memory and not as a present experience.
Also in organic cases such real memory hallucination can oc-
casionally appear. Thus a senile patient frequently related to us, how
he was attacked in his room last night by robbers, who tied one of
his arms on his back, and used his other arm with the hand as a scoop
to get out the gold and silver from his own money chest. Sometimes
it could be demonstrated that he neither slept nor hallucinated during
the night in which he located his adventure. As a matter of fact no
hallucinations of the senses have ever been confirmed in him.
In confabulations it is also a question of free inventions which are
taken as experiences. They fill a memory gap, frequently turn out
to have been produced for just this purpose, and change from moment
to moment. Indeed they can be provoked and guided while memory
hallucinations can no more be changed than a delusion. One asks
an alcoholic Korsakoff patient where he had been yesterday, and
without any reflection he recounts with great accuracy that he took a
walk to the nearby mountain. If he is then asked whether he Has
not seen the doctor, one can expect with considerable certainty that in
pronounced cases, the patient will answer in the afiirmative and will
describe where he had seen him and about what they talked together.
Now and then such an invention adheres to memory, and what is
remarkable, also when real experiences are forgotten from minute to
minute.
Unfortunately the term confabulationalso used for vivid memory
is
hallucinations and for phantasy

half manifestations of
conscious
schizophrenia. We must, however, adhere to the concept in the above
given sense of the confabulation, for thus conceived it is a sign of
organic psychoses when observed in non-delirious states. It would
be good if the name should not be applied to other anomalies.
The most vivid confabulations are seen in many alcoholic Korsakoff
cases; almost their whole psychic activity often consists only of con-
fabulations. Many paretics, especially the manic types, spontaneously
confabulate in a very profuse manner. Confabulations play the
smallest part in senile forms, still, even here it is in many cases quite
easy to evoke the symptom if the patient is asked, for example, what
he did yesterday (embarrassment confabulations).
Related to confabulations are phantasies which on occasion are
formed by everybody, and are more spontaneously produced by the
poets. Gottfried Keller's Griiner Heinrich relates in an episode which
is undoubtedly created from the poet's own childhood, how when in
the abc class he was painfully taken to task for using ugly words
which he accidentally absorbed, how in his embarrassment he named
some place and name, following which, to further questions, a more
complicated scene emerged with all possible details, which he believed
was an experience from his own life.
What happened here to the future poet occurs habitually in Pseudo-
logia Phantastica. Pseudologues have a vivid phantasy, they invent
for themselves some fairy story about princely lineage or some other
and act upon it. In contradistinction to confabulations
desirability
and memory hallucinations, the real worth of their phantasies be-
comes conscious to the pseudologues as soon as they are recalled to
them by the events, and sometimes even without this; in every case
a part of the fancies are just lies. Yet, for any long period the
pseudologues are capable of ignoring the fact that they are living in
a dream world. This circumstance, with a great talent to put a role
into operation, which for inner reasons is regularly found at least in
all cases that come for investigation, gives them the facility to de-
ceive their environments, and if they are not very moral they are
destined to become panhandlers. Pseudologia phantastica is therefore
a general anomaly and not merely one of memory. The following
^^
cases will serve as illustrations:
A young man good breeding fancied so vividly that his mother
of
died, that he rode home
dressed in mourning carrying a wreath of
flowers of his mother's funeral. Another young man had a quarrel with
a friend. He then pictured to himself a duel with his antagonist whom
he shot dead, and that he informed the latter's father of the unfortu-
nate outcome of the duel. I found one prisoner in his cell projecting
a plan for an English park. He admitted that he had already pre-
pared in his mind the speech he was to deliver to his dinner guest
on the occasion of the first hunting party.
Among the parafunctions of memory one may mention in the first
place the identifying memory deceptions. Even the healthy person
has sometimes the feeling, particularly wh"en fatigued, that he had
'^
Aschaffenburg, Die pathologischen Schwindler, Allgem. Zeitschr. f. Psych.
909, Bd. 66, p. 1073.
already experienced something that happens to cross his mind at the

time being. An attempt was even made to trace such deceptions to
the idea of the transmigration of the soul. It occurs more frefjuently
in neurasthenics. Now and then this manifestation is also observed
in schizophrenics and epileptics, who are usually peeved over it and
imagine that some comedy is performed for their benefit. A schizo-
phrenic that I have known, believed for a long time that whatever
he experienced he had already gone through in exactly the same way
a year before. An epileptic who in a twilight state saw in everything
that happened to him, especially visits and the doctor's words, a
repetition of a few weeks before, finally remarked that everything
repeated and placed the actual experiences in a great number
itself,
of former twilight states, a fact which at the time caused him marked
excitement.
Just as the memory qualities are in this case connected with ideas
to which they do not belong, so also do we find reminiscences in
cryptomnesias which have lost the memory and appear to the
qualities
patient as new There are learned men who at first nega-
creations.
tively reject every new idea and then digest it consciously or uncon-
sciously, and finally, accept it, if it suits them, but then absolutely
forget that these are no discoveries of their own, and even go so far
as to present them as new to the very people who discovered them.
Senile patients often relate a story at a social gathering as new, which
they have heard only a few minutes before from somebody else at the
same gathering. Frequently, however, the cryptomnesia embraces
the whole wording. In the beginning of this century an art critic was
once accused of plagiarism because he reproduced word for word a
criticism of somebody else. The whole state of affair points that it must
have been a case of cryptomnesia. Jung has also demonstrated
cryptomnesia in Nietzsche who verbally put a paragraph from
the Seeress of Prevorst into his Zarathustra, and what is more, in
quite a senseless connection.^^ Helen Keller's unconscious repro-
duction of the fable of the Frost King caused her a great deal of
annoyance.
As reduplicative memory deception, Pick has described a mani-
festation sometimes seen in organic patients, which consists in the fact
that the patients do not duplicate the actual act but double the details
of it. They say that they have already been examined in the ver>''
" C. G. Jung, Zur Psychologie und Pathologie sogenannter okkulter Phano-

mene, Stuttgart, Mutze 1902 Especially instructive is Flournoy's "Des Indes
a la Planete Mars, Paris and Geneve 1900. (Etude sur un cas de Somnam-
bulisme avec glossolalie.)
no TEXTBOOK OF PSYCHIATRY
same clinic by the very same physician, having the same name, there
are therefore, two such physicians and clinics,
5. DISTURBANCES OF ORIENTATION
Wernicke divides disturbances of orientation into autopsychic or
those referring to the individual's person, somatopsychic or those re-
ferring to the individual's body, and allopsychic or those referring
to the outer world. This differentiation has a specific meaning; thus
patients in alcoholic deliria are never autopsychically disoriented,
that is, they can give a good account of their personal matters, their
residence, occupation, and past life, whereas allopsychically they ar
usually deeply disoriented, especially as to time and place. However,
this classification fails to give proper emphasis on the element of the
situation which may form part of allopsychic as well as autopsychic
orientation. Instead of somatopsychic disorientation we prefer to
speak of somatic illusions and hallucinations.
In all organic mental diseases of a higher grade, the primary
auxiliary functions of orientation, perception, memory, and attention
are affected, and in addition there is com-
also a disturbance of the
prehensive orientation itself. Orientation as to time and place, and
later also as to the situation, are falsified. The patients are not aware
that they are kept in an institution, or of the reason thereof, nor do
they recognize as such the doctors who are treating them. Not in-
frequently one observes in the insane asylum, that orientation as to
situation which is otherwise less liable to injury is falsified before
orientation as to time. This is due to the fact that the patients do
not wish to be in such a place.
Orientation as to time and place are always present in Schizo-
phrenia; they are often very well preserved unless interfered with by
secondary influences such as delusions and hallucinations. The patient
who believes he is Christ usually considers himself 1900 years old.
For affective reasons the calendar itself is often directly falsified.
Places are nearly always correctly recognized by clear Schizophrenics.
On the other hand, orientation as to the situation is in most cases
incorrect, at least in interned Schizophrenics. The patients cannot
comprehend that they are considered sick, they believe themselves
unjustly confined, etc.
Furthermore, orientation can be falsified in all its relations by
hallucinations and illusions. If a patient sees hell instead of the
hospital ward, or a devil instead of an attendant, he cannot imagine
himself in an insane asylum. The strange part of it is, that in such
.
states of schizophrenia, hardly ever in other diseases, the correct

orientation mostly accompanies the false one; one might say that
there is a double orientation. Depending; on the constellation the
patient uses now one, then the other orientation, and often both
together.
In all states of vivid hallucinations which conceal the real per-
ceptions, thinking is also disturbed, often in a very profound manner,
as for example in epileptic twilight states where it is sometimes more
pronounced than in our dreams. In some cases the disturbance of
thinking seems to be the chief cause of the disorientation, as in cases
of confusion (amentia). That a schizophrenic delirium should appear
to last thousands of years, and a dream of a few seconds many hours,
fits in well with the absolutely changed course of the psychic
mechanisms.
Disorientation as to time and place is, therefore, one of the most
constant partial symptoms of all disturbances of consciousness, such
as deliria, crepuscular states, confusions, amentias, and other states.
Not seldom we also find here some autopsychic disturbance (referring

to the person)
6. DISTURBANCES OF CONSCIOUSNESS
Under the expressions "Disturbance of Consciousness" and "Cloud-
ing of Consciousness," which do not fit in with the rest of our termi-
nology, but for which we have not yet found substitutes, we conceive
a number which the general relationship of the psychic
of anomalies in
processes, usually including orientation, is disturbed, or in which
psychic processes are forcibly hindered from coming to conscious-
ness." The first type of disturbance is especially found in the states
of Confusion mentioned above,^^ which may arise from very different
fundamental disturbances. Marked confusion with numerous halluci-
nations was also designated as Amentia. Kraepelin uses this term
for a definite morbid picture.^^ Deliria and Timlight or crepuscular
states are concepts everywhere used, even though they are very dif-
ferently defined by different authors, and not clearly differentiated
from each other, nor definitely limited.
What one calls Deliria are mostly states of incoherent thinking
combined with hallucinations and delusions, which show a certain
activity and run a rapid course. They usually accompany other dis-
'^The "conscience" of the French is a broader term than our modern con-
sciousness. Even simple delusions are "troubles de la conscience."
=^
Cf. p. 86.
'^Cf. Special part.
and sud-
eases, such as infections, fevers, exhaustions, toxic states,
denly appear in the dark room in cases of diseases of the eye. But
in a certain sense, some states of Schizophrenia and manic depressive
insanity, may also be designated as deliria. Disturbances of con-
sciousness in febrile diseases were all wont to be designated as deliria,
although many of them clearly show connected ideas along the line of
complexes and, therefore, rather belong to the "twilight states." In
the newer German psychiatry the term "delirium" most frequently
stands for ''Delirium tremens." The memory of deliria is usually
imperfect or totally absent.*"
The name Twilight State suggests especially a systematic falsifica-
tion of the situation. He who is familiar with these states finds sense
and a more or less logical connection in the acts of the patient. The
onset and termination of twilight states are most often sudden, the
duration is brief, lasting from a few minutes to a few days, rarely for
weeks or months.
In the (less frequent) oriented twilight states the associations are
narrowed. There seems to be present only a single purpose striving
to accomplish what is necessary, while the rest of the personality, at
least to the extent that it runs counter to this purpose, does not exist.
The patients act in a definite direction, they run away, take a journey,
make a purchase, commit a crime which otherwise would be foreign to
them; they do all that without any regard for themselves or others,
even though at times, especially in the case of forbidden acts, they
endeavor to protect themselves against discoveries. During this period
if they can be observed they usually strike one as abnormal ; at times,
however, they can use correctly ordinary means of intercourse, can
associate with fellow travelers, and can even visit relatives, without
betraying their condition.
The ordinary disoriented 'twilight states present themselves quite
differently and yet, as daily transitions show, they are only an exag-
In spite of a certain coherence, which might
geration of the preceding.
be compared with a dream, thinking is not clear or it may even be
confused. The connection with the outer world is altogether inter-
rupted or falsified by illusions and hallucinations of the visual and
auditory types, especially the former. The patients see robbers, ani-
mals, devils, or the Almighty with many saints; they actually believe
themselves in a dream-like situation and act accordingly. As in the
dream the content of the twilight ideas may be anxious, indifferent, or
*'The French conception of delirium is much broader. They even call

delusions occurring in clear consciousness delirium. Bouffee's delirantes are,
according to Magnan, transitory deliria in his "degenerates."
rapturous. Anxious and hostile illusions provoke the patients to acts

of violence; killing even several people is not uncommon. Sexual ex-
citements lead to rape and murder. An epileptic set fire to his work-
shop in the belief that he was lighting a fire under a lime pan. States
of rapture are designated as ecstasies. In such states association with
the outer world is so completely interrupted that an absolute analgesia
exits. The patients see the heavens open, associate with the saints,
hear heavenly music, experience wonderful odors and tastes and an
indescribable delight of distinct sexual coloring that pervades the
entire body.
Some twilight states have a definite purpose such as to represent
illnesses and the like, of which the best known type is the so-called
Ganser state. The varieties of these forms are indicated under the
Syndromes.
The causes of twilight states are very varied.Many have their
origin in an affective necessity and schizophrenics turn away
; hysterics
from reality because it has become unbearable. An engagement which
has been broken in reality continues in the twilight state and leads
to marriage. Some hysterical twilight states repeat hallucinatorily an
emotionally accentuated event, especially of an ambivalent nature,
e.g. a sexual attack. Less frequently the delights of ecstasy can be
conjured up. The basis of twilight states are the hysterical, epileptic
or schizophrenic disposition, toxic conditions, especially pathological
intoxication, also sleep, as pavor nocturnus, somnambulism and hyp-
nogogic intoxication, less frequently it is migraine, concussion of the
brain, and brain disturbances after hanging, occasionally it may also
be caused by severe excitements as in the case of psychopathies. In
hysteria the entire mechanism is psychogenetic in the toxic states of
;
epilepsy and schizophrenia, it is the brain disturbances which usually

furnish the necessary factor. All these states produce clear thinking
which becomes systematized as a result of affective aims, in conse-
quence of which the disturbance assumes the form of a twilight state.
The disturbance of thought then has a twofold origin, one in the toxic
confusion, the other in the systematic formation with its misunder-
standing of reality. It is self-evident, that in epilepsy as well as in
schizophrenia the relation of the two causes may be entirely different.
There are extreme cases in both directions, on the one hand conditions
in which the organic completely dominates the picture, and on the other
hand those which are of an entirely psychogenetic (hysterical) char-
acter and in which acute changes of the fundamental condition play no
part. Where primary anxiety exists, as is often the case in epilepsy,
the content of the delusion is colored in this sense.
Naturally, we often observe very mild twilight states and deliria,
inwhich the thought process is only more or less unclear. These mild
forms together with deliria and twilight states may be called pro-
visionally turbid states.
There is still another gradual weakening of consciousness which
is shown by the must be endowed with an
fact that external stimuli
abnormally great intensity in order to become conscious. Mild states
of this sort are called cloudiness, a name that may also designate light
grades of the twilight states. Similar states that are somewhat deeper
and especially those in which movements are retarded are designated
as somnolence; those in which only stronger stimuli produce reactions
are called torpor or sopor; and those in which there is no longer any
reaction are called coma. In the last condition one assumes that there
is a state of actual unconsciousness, i.e., an absence of conscious
psychisms. This is naturally something entirely different from the
falsely designated unconsciousness in a twilight state.
In all these disturbances the field of consciousness, that is, the num-
ber of simultaneous ideas, is greatly diminished; in the twilight states
this is more or less systematic, in other conditions it is diffuse.*^
There is also a purely functional attempt to keep occurrences out

of consciousness. When attention makes way for a certain group of
ideas it blocks at the same time all others. In a cheerful mood un-
pleasant thoughts are automatically kept away. In melancholia cheer-
fulness cannot even be thought of. The katathymic exclusion of un-
bearable complexes from consciousness (repression) belongs to this
category. In all these cases the functions which are not admitted
to consciousness may be entirely impeded or they may lead an un-
conscious existence.*^
Sleep is a kind of physiological disturbance of consciousness which
symptoms. I do not know
also gives occasion for several pathological
whether or not one always dreams in sleep. In our present state
of knowledge the forms of association in dreams are the same as in
schizophrenia. The psychopetal functions usually are extremely re-
stricted in sleep, partly in such a way that only strong stimuli arouse
reactions, partly, and this is more important, in such a way that the
main part of the stimuli is shut off regardless of its intensity, and
its place is taken by a smaller group, which is generally or under
certain constellations especially important. Thus a nurse sleeps
through a great noise but is awakened by a slight respiratory change
in her patient. The psychofugal connection with the outer world,
*^
For alternating consciousness Cf Personality. .
" Comp. the Unconscious, p. 8.

at least as far as concerns the voluntary muscular system, is usually

limited to movements that make respiration easy, change uncomfort-
able positions, ward off stimuli from insects, etc. Movements that
are not carried out are falsely conceived through kinaesthetic halluci-
nations, except in nightmares, where the paralysis is felt, and what
is not quite the same thing, the interruption between volition and
motility comes into consciousness.
Falling asleep is the result of an influence, or a special act, which
is put in operation by the predisposition to fatigue, a feeling which is
psychically determined. Perhaps the only thing of importance for

psychotherapy is the psychic participation in the initiation of sleep.
The essential thing is the "suggestion of sleep." To be sure, energetic
mental occupation in the evening may for a time hinder the command
to sleep. But ordinarily, it is the affects that exclude sleep. For
example, one is particularly apt to remain awake when one is pleas-
antly or unpleasantly excited, when one is afraid of not being able
to sleep, or when one "imagines" himself disturbed by a definite
sensory impression. Here the sensory impression has really no signifi-
cance, compared with the psychic attitude. The psychotherapist must
firmly maintain that when some one cannot sleep, let us say, because
his neighbor snores, that it is his own attitude and not the neighbor's
snoring that is the cause to be considered. One can sleep in the worst
noise if one is able to assume a proper attitude, and at the same time
one can be awakened by the slightest sensory impression for which
there is an association readiness. Millions sleep through the street
noises of the metropolis. One
most important neurotic dis-
of the
turbances of sleep undoubtedly based on the fact that emotionally
is
accentuated complexes, which are more or less repressed by the day's

work, make themselves felt as soon as purposive thinking ceases.
What the recuperative function of sleep is, we do not know. At
all events it is under a special influence, because, in states of depres-
sion, for example, one can dispense for many months with sleep, in
the sense of disturbance of consciousness and association, without
apparent results, while an artificial insomnia of only eight days is
certainly fatal. Moreover a partial insomnia has few or no imme-
diate ill effects, if one succeeds in lying quiet and not exhausting one-
self in the "struggle for sleep."
The dream is classed with the twilight states because ordinarily it
does not influence conduct. Nevertheless in the sleep of no person

are the connections with the outer world maintained only through
the merely necessary centrifugal and centripetal impulses. Through
groaning, twisting, and through many somewhat uncoordinated move-
ments and similar expressions one even in sleep some internal
satisfies
or external requirements. A normally existing

slight increase of these
motor commands permits the release of any acts corresponding to

dream images, and leads to twilight states of somnabulism, hypnogogic
intoxication, and pavor nocturnus.
Somnambulism occurs in nervous persons of all types, in epileptics,
and to a mild degree, at times in people who must be considered
healthy; this is especially the case in youth. There are all sorts of
transitions from simple movements and mumbling in sleep to more

complex acts as well as walking which sometimes takes place on the
roof. Most frequently such little acts are performed that correspond
to the daily occupation; these are sometimes senseful and sometimes
senseless. Complexes may also find expression in somnambulism
(Lady Macbeth).
Hypnogogic intoxication (Schlaftrunkenheit) may occur during
spontaneous awakening in people who seem perfectly well, but more
frequently it follows a rough waking, which generates a dream, and
induces motility before the dream disappears. In rare cases some-
thing clumsy is then performed, indeed, under the influence of terrifying
ideas an attack or murder may be perpetrated. A variety of sleep
intoxication which is especially frequent in children is pavor noc-
turnus. It usually manifests itself in the beginning of the night when
the ones start with an anxious cry and despite all attempts to
little
wake or quiet them, become mentally clear only after several minutes
or even a longer time. The syndrome is often altogether psychically
determined, in other cases it is favored or absolutely induced by
respiratory difficulties. The twilight states of sleep are also regularly
followed by amnesias.
"Clear Mindedness" ("Besonnenheit")

In contrast with disturbance of consciousness there is "clear
mindedness," a concept that is plain to all, although it cannot be quite
defined. In states of clear mindedness every disturbance of con-
sciousness is lacking, orientation is good, the affects produce neither
unconsidered acts nor stupor. The most inhibited melancholic can
think normally within the range of ideas accessible to him, and can
orient himself, he is so to speak, clear minded. The most chronic
states of schizophrenia do not lack clearmindedness, although, under
certain circumstances, the patients act in an entirely senseless way.
The major part of the thinking function runs along smoothly; orienta-
tion especially is good, and there is always a possibility of discussing
many things sensibly with the patient. The outward indications of

clear mindedncss, according to Jasper, are orientation,

and the ability
on questions and to take some notice of them.
to reflect
The concept is important because in clearmindedness identical
symptoms have an entirely different significance than in states of
disturbance of consciousness. In twilight states the most confused
delusions indicate nothing concerning the prognosis, somatic hallucina-
tions indicate almost as little. In clear mindedness both symptoms
point to a grave condition, the latter especially to a schizophrenic
condition.
7. DISTURBANCES OF AFFECTIVITY
Since the affective dispositions fluctuate greatly in different people,
they also most readily cross the borderline of the "normal." The
so-called psychopaths are really nearly all exclusively or mainly
thymopaths. Furthermore, since affectivity dominates all other func-
tions, it assumes a prominent role in psychopathology generally, even
in slight deviations, not only on account of its own morbid mani-
festations, but even more because in disturbances in any sphere, it
is the affective mechanisms that first create the manifest sj'mptoms.
What we call mostly thymogenic. The influence of the

psychogenic is
affects on the associations produces delusions, systematic splittings of

personality, and hysteroid twilight states; repressed pain is the source
of most neurotic symptoms, while displacements and irradiations
produce compulsive ideas, obsessive acts, and similar mechanisms.
Ambivalent feeling complexes, that is, viewed from the active side,
inner conflicts, which the individual cannot settle but must repress,
prove especially pathogenic. To avoid repetitions the causal signifi-
cance of the affects will here be passed over, and only the etiolog>'
of certain symptoms will be briefly considered. Only the phenome-
nology of the affective disturbances will follow here.
Many affective disturbances come, as it were, from within, from
the physiology of the brain and from the general chemism. Here one
is perfectly right in thinking of the "inner secretions'' in the widest
sense, without knowing anything definite about them. To this one
may add the affective bases of melancholia and mania, the euphoria
of chronic alcoholics, and most of the moody states of epileptics and
imbeciles, and naturally also the congenital abnormal emotional states.
The last may have a significance of their own, as in the case of "chronic
moods," or ma}'' be the foundation on which other diseases originate.
To become an hysteric or paranoiac one needs a distinct aft'ective con-
stitution which is usually congenital. Such morbid constitutions are
:

almost always exaggerations of the character variations of the normal
type or "temperaments."
Other affective disturbances are qualitatively correct but quantita-
tively exaggerated reactions to an experience, which usually have their
origin in the constitution. Thus a mother loses her child, and does
not recover from the blow for years, remaining in mourning all the
time. She shows a morbid protraction of the affect. Or she reacts
so strongly to her misfortune that she can no longer work or eat, is
entirely absorbed in the anguish and can in no way be distinguished
from a melancholic. Here one sees a morbid intensity of the affect.
In this way certain anxiety affects may lead to affective stupor ^^ and

confusion, manifestations that make the examination of children and
oligophrenics particularly difficult, and often lead into entirely false
trails.
Reactions in themselves normal may appear morbid because the

intellectual processon which they are based is abnormal. A paranoiac
believes that he has made a revolutionary discovery which makes him
emotionally exalted, or he considers himself persecuted and becomes
irritated. In both cases the affects are normal reactions to a morbid
idea; in itself the formation of the affect is normal. In the same
way there is, apathy in organic cases, who
for example, a secondary
do not understand many experiences and, therefore, naturally cannot
react to them. As soon as they grasp the true significance of any-
thing the same patients react to it in a very active manner.
Morbid irradiations and affective displacements are secondary dis-
turbances in an entirely different sense. This is shown in the following
examples
The patient feels disgust and anxiety at hornlike soup ingredients
and other things shaped like horns because she was once frightened
by a bull whose genitals and horns particularly impressed her. A
schizophrenic woman, a patient of v. Speyer hated her landlord be-
cause he had cheated her husband. When she was taken with labor
pains in an isolated country place, instead of a mid-wife the wife of
the landlord had to assist her. The hate was transferred from the
landlord to his wife, and from the latter to her own child which she
tortured to death.
Most affective disturbances are transient episodes. Those which
continue are usually congenital, less frequently acquired, as the
chronic euphoria of alcoholics, the lability and some persisting euphoria
or depressive states in organic cases, as well as the perseverance and
intensity of the affects in epileptics.
"Cf. p. 80.
.
Morbid Depression
In general depression, all experiences, inner and outer, are toned
with psychic pain of various kinds. The milder cases resemble
normal "downheartedness." It is not so easy, however, to read one-
self into the affective situation of the profound melancholic. He
has lost everything that was of value to him, and nevertheless he
expects still worse for himself and those he loves, the worst that one
can think of. Through "diversion," i.e. an increase of sense impres-

sions, which are really only unpleasantly toned, the pain is usually
increased, except in those cases where the feeling that the patient
does not feel well anywhere, leads to a continuous change of environ-
ment. In many cases perceptions take on the character of strange-
ness, of uncanniness, and monotony; optical impressions are double
dyed gray, things seem to stand crooked, and foods lack their peculiar
flavor. Thinking, in itself, is not only colored by unpleasant feelings,
but proceeds with difficulty, and only ideas of a painful content can
be thought out. Thoughts of a pleasant content are flighty and
transient, leaving no influence on deliberation and the general con-
dition. Only with great difficulty can the patient resolve to act, and
when he succeeds in making a movement, it is with great effort.
The mental stream is inhibited,** it runs more slowly and the
patient must exert effort to think out anything; a change of the
ideas requires exertion or is even impossible. The patients always
fall back on the same ideas of a sad content or they never get rid
of them and always carry with them the same desperate thoughts
(Monideism)
Among the varieties of depression, of which we mention only grief,
desperation, and remorse, anxiety occupies a particular place. To
be sure, it is often combined with the common forms of depres-
sion so that it merely complicates the latter. Anxiety may also
appear in isolated form, which accounts for the fact that starting
from different viewpoints some authors wish to differentiate an abso-
lute anxiety psychosis and an anxiety neurosis as special forms of
disease. Anxiety undoubtedly has different sources. In many cases
it is plainly connected with respiratory difficulties as seen in dis-
eases of the heart, in the respiratory organs, and in the blood. Further-
more, anxiety undoubtedly connected
is some way with sexuality,
in
a fact which we knew for a long time but which Freud first made
clearer. Stimulated but unsatisfied sexuality leads to various forms
of anxiety. Frend's conception is that the sexual tension, or the sexual
**
Cf. p. 74.
affect, isconverted into anxiety, which may not be right, although
sexual satisfaction maj^ under certain circumstances remove anxiety,
and although anxiety appearing in attacks, as is more generally as-
sumed, may be converted into other syndromes, such as inordinate
hunger, attacks of perspiration, asthmatic attacks, diarrhoea, dizzi-
ness and similar symptoms. We also know that normal sexuality has
an anxiety component and that not seldom orgasms are generated by
anxious situations such as hurrying to catch a train, scolding from
a teacher in school, and difficult tasks. In many cases of psychoses
connected with anxiety we see an irresistible impulse toward onanism
that disappears with the affect. But there must be other patho-
logic sources of anxiety. Wherever depression in general originates
from physical processes, which we do not as yet know, anxiety too,
may be generated, at least as far as we can judge at present;
in other words, in all states of melancholia of the most diverse
diseases.
In a more striking manner than the other affects, anxiety may
exist without any association with ideas: The patient may feel
anxiety without knowing why, and be absolutely certain that there
is no ground for it ("free floating anxiety"). In many cases anxiety
itself creates the ideas to which becomes attached and which it
it
apparently conditions. In most cases, however, one can easily dem-

onstrate that such ideas are secondary; the anxious patient seizes
on something that might produce anxiety such as, an uncertain
financial condition, an insignificant symptom of a bodily disturbance
in himself or others, or on any mistake that he made in the past;
and even when circumstances can convince him that the ideas were
wrong the anxiety does not improve in consequence but it attaches
itself to a new idea. Often it creates one as an anxiety delusion from
pure fancy without any external connection.
Katathymic anxiety referring to a particular member of the family,
present in normal and abnormal individuals, is as a rule the expres-
sion of a repressed wish that this member should be dead. A latent
schizophrenic woman had a by her husband whom she did
child
not love. Her anxiety was soon noticed even by the midwife when
she expressed the idea: "I should only wish that nothing happen
to the child!" A few months later she poisoned it. A young woman
shows her illness through excessive anxiety for her mother. As soon
as her mother has gone out, she has to stand at the window to see
that nothing has happened to her, or to see if she is coming back. She
is strongly attached to her father and unconsciously jealous of her
mother.
Anxiety is more frequently and nnore visibly accompanied by

physical symptoms than most of the other affects. It is especialiy
often associated with an increased cardiac tone wliich is felt in the
chest as something heavy, pressing and often also something painful;
these feelings may be present even when the by no means un-
common palpitation is absent. As in angina pectoris the pain may
even irradiate into the left arm. In the abdomen, too, a rolling or
pulsing, or a hot stream may be felt, or the latter may appear to
rise to the head, where other bad feelings, such as knocking, press-
ing, and fullness may exist. "The Anxiety" is often localized in
the place where one has the greatest sensation; thus one speaks of
praecordial anxiety, which is the most frequent concomitant of all
depressions, or of head anxiety, etc.
Depression in general usually evinces distinct physical symptoms.

The entire turgor vitalis is diminished, the patients appear older than
before, and the metabolism and appetite become decreased. The mus-
cular tone, especially of the extensors and abductors, is decreased,
the latter move with and all show
greater effort than their opponents,
as little and are as slow as possible. As a result, the
activity
patient's posture becomes uniform, languid, and bowed, and mani-
fests a tendency to draw in the limbs. The handwriting usually shows
a tendency to slant the letters downwards.
In some cases, especially those showing anxiety, instead of motor
retardation there is a desire to express or get rid of the inner ten-
sion throughmovements {Melancholia agitata). In contrast with the
common cases of melancholia some patients have no feeling of fatigue
and run around continuously and when permitted take tireless
walks. In contradistinction to the normal we see more rarely,
that morbid anxiety retards movement and the psychic processes
generally.
Respiration is easily disturbed, in that inspiration becomes less
free,and connected with this are the frequent feelings of oppression.

The ipidse is mostly full and small, and the artery contracted. Anxiety
increases the blood pressure.
An increased tone of the throat inuscles very often causes an annoy-
ing feeling of strangulation causing the patient to refuse nourishment;
it also produces pressure in the chest. In addition all other possible
dysaesthesias may accompany depression.
Depressions occur in the most varied psychoses. The tendency
to it increases with age, and wdth increasing vascular disturbances
there is more anxious excitation. Depression is the essential symp-
tom in all states of melancholia, and above all in those of manic
depressive insanity. Besides these, there are certainly depressions of
other kinds which we cannot as yet characterize. Anxiety is an
important concomitant of phobias, obsessive ideas and obsessive acts.
The Pathological Elated Mood (Exaltation, Euphoria)
We can differentiate two kinds of exaltation that are, however,

connected by all the intermediate stages. In simple euphoria one
enjoys the world and one's own existence in a particularly lively
way; sensations and thoughts are pleasantly accentuated. Among
the healthy of this type we have the sunny dispositions, while among
the sick we see some paretics not really of the manic type, less often
cases of senility, and at times, also epileptics in a euphoric mood
{morbid euphoria) In the second form, which deserves more the name
.
of exaltation in a narrower sense, we also see self-consciousness and

with it an enormous enhancement of desires and claims. This nat-
urally results in conflicts and leads regularly to severe outbursts of
anger. The conditions therefore, in which one sees this symptom to-
gether with flight of ideas and pressure activity, are designated
as mania and the affective state as manic depression. In a somewhat
milder form and without the flight of ideas we see this exaltation in
the common alcoholic euphoria.
Naturally, the pleasant accentuation may here, too, evince various
shades such as cheerfulness, lack of restraint, aesthetic enjoyment,
and a general ineffable feeling of delight; the last is especially ob-
served in paresis. The accompanying the ecstasy is
blissful feeling
principally something quite different than manic euphoria, both in
the quality of feeling as well as in relation to the mechanism of its
origin, which in hysteria is regularly katathymic, in epilepsy usually
autotoxic, while in schizophrenia sometimes more of the one, then
again the other.
Corresponding to the nature of the positive affects in the normal,
the mood of these patients is much more changeable than in de-
pressed cases. They follow the different topics of conversation with
their affective fluctuations, but generally do not abandon the euphoric
state. In a few cases, however, such fluctuations may go as far as
depressions in which the patients may be moved to tears by a sad
performance.
Just as we have retardation in depression, so in exaltation we
often have a fluent course of ideas up to flight of ideas; the ready
translation of thoughts into acts is regularly observed. Manic patients
look younger, the turgor vitalis is increased, the posture is the direct
opposite of that of depression. The other physical symptoms are less
I GENERAL PSYCHOPATHOLOGY 123
marked than in depression, even though the pulse has a tendency to

be full and soft.
Exaltation, like depression, may appear intercurrently in every
mental disease; in manic states it forms part of the picture and in
manic depressive insanity it is a component of the disease itself. As a
chronic state it occurs in alcoholics, also as a partial symptom in
psychopathic constitutions.
Morbid Irritability
A uniformly overstrong activity of all affects may be the founda-
tion of an abnormal character as well as of hysterical and similar
morbid pictures. Furthermore, such an anomaly occurs in the organic
psychoses and in epilepsy, and temporarily, also, in simple exhaus-
tion where one may see all kinds of "affective crises," not only of
the endogenous but of the reactive depressive type. However, what
one understands as morbid irritation is a special tendency to ill-temper,
anger, and rage.*^ It occurs even in neurasthenics, who can become
exceedingly angry over all stronger sense impressions and every dis-
turbance. In the really insane we see it, as was mentioned, as one
of 'the manifestations of exaltation, then again it may accompany, as
a more independent affective disturbance, all forms of dementia. This
is,in part, founded on the fact that rage is the normal reaction to a
dangerous situation that one does not understand; under such cir-
cumstances reflection is useless, on the other hand, a blind effort to
strike random or tear away without consideration for the en-
at
vironment and the integrity of one's own body, may at times save
one's life.
On the contrary, in other irritable characters we perceive the in-

tellectual disturbance, the false conceptions of the surroundings with
morbid self-reference, as a result of the affect of irritability, and even
though these people always appear somewhat onesided or "narrowed"
they sometimes retail! an intelligence which is, on the whole, good.
Imbeciles manifest in addition moodiness which comes from
within, and easily assumes the form of irritated cloudiness of thought.
Here we see most frequently a peculiar symptom of rage, that actually
turns the action against themselves, which rarely occurs in other
patients. The patients tear their hair, scratch their face or destroy
other things so that they perforce hurt themselves. Often they only
tear their clothing. Such damaging of the environments, including
their own clothing, are very common in schizophrenics, at times it
is the result of excitations coming from within, then again it is a

^The disposition to anger is not always identical with rage.
reaction to outer harmless experiences. In severe cases of schizophrenia
outbursts of rage and anger are often the only remaining signs of
affects, while in the milder cases less severe irritability is the only
indication of the disease that impresses the environment. In epileptics
we often see a chronic irritability as a partial manifestation of the
general increase in intensity of the affects, and further, as a passing
state of depression in quite the same way as in imbeciles.
Apathy
Apathy in the sense that the affects are destroyed probably does
not occur in the psychoses; as a matter of fact we see all affects
retained in the brain in the most severe organic destructions. Never-
theless there are many cases of schizophrenia which for years show
no impulses or affects. In senile patients who no longer show a
proper understanding of this world we sometimes see a total lack of
interest in everything that occurs about them, which is much less
frequently the case in matters of personal contact with them.
Melancholies, who immersed in their misery that everything
are so
else appears insignificant, are sometimes mistaken as apathetic.
Many of them maintain that they no longer have feelings, that they
are apathetic, because in the face of the great agony entailed in the
disease, they can no longer discern any feelings for their own family.
In contrast to neurasthenic irritability there is a neurasthenic in-
differencewhich no longer bothers with anything. Even more fre-
quently do hysterics shut off their affects altogether for a shorter
time, so that they appear apathetic. The chronic and totally apathetic
"psychasthenics" whom the French describe, we undoubtedly would
include with the schizophrenics.
Variable Duration of the Affects

An abnormally long duration of the affects occurs in many people
not mentally deranged, who cannot get over an ill humor and must
always carry with them, for instance, a hatred. In epilepsy, the
affects, once aroused, also persist an abnormally long time, even
when other experiences intervene. A slight annoyance may also
excite a congenital feeble-minded person for days. Such patients
possess too slight an affective distractability.
More important and better known is the excessive lability of the
affects, their abnormally brief duration and their increased affec-
tive distractability. Children are normally labile; they are rightly
compared with seniles; except that all organic cases should in this
respect be mentioned together. The affects are very easily aroused
in them, but have a short duration; they are especially capable of

being too easily diverted. Lability of the affects is very common also
in the intervals of more advanced manic-depressive insanity. Im-
beciles, too, may suffer from the same defect.
Emotional Incontinence
Most patients with too great a lability of feelings display less
control than the normal. They must give in to every affect, whether
they express it or act in accordance with it. Yet lability and in-
continence do not always run parallel. There are people without
noticeable lability who cannot control their feelings. One of our
imbeciles, who was none the less a pretty good workingman, could
not, to his sorrow, play cards, because a smiling or a sad countenance
always betrayed to the other players whether he held good or bad
cards so that they could act accordingly. As far as action is con-
cerned one can say that a real control of pathological affects is not
common in the different mental diseases. When an affect is present,
the patient usually acts accordingly. The best dissimulators are
melancholies, and they resort to it especially for the purpose of getting
an opportunity to commit suicide.
Affective Ambivalence
Even the normal individual feels, as it were, two souls in his
breast, he fears an event and wishes it to come, as in the case
of an operation, or the acceptance of a new position. Such a double
feeling tone exists most frequently and is particularly drastic when
it concerns persons, whom one hates or fears and at the same time
loves. This is especially the case when sex is involved which in
itself contains a powerful positive and almost equally powerful neg-
ative factor; the latter conditions among other things, the feeling
of shame and all sexual inhibitions as well as the negative valuation
of sexual activity as sin, and the evaluation of chastity as a cardinal
virtue.*^
But such ambivalent feeling tones are the exception with the normal
person. On the whole he makes a decision from the contradictory
values; he loves less because of accompanying bad qualities, and
hates less because of accompanying good qualities. But the abnormal
person often cannot bring together these two tendencies; the hate
and love manifest themselves side by side without the two affects
weakening or even influencing each other in any way. He wishes
*"
Bleuler, Der Sexualwiderstand, Jahrbuch f. Psychoanalytische Forschungen,
Bd. V. 1913.
his wife's death and when hallucinations picture it for him, he is
desperate, but even then, besides crying he can at the same time
laugh over it.
ambivalent complexes that influence pathology and

It is chiefly
many expressions of the normal psyche, such as dreams, poetry, etc.
In schizophrenia they come to light quite openly. There we often
see directly the ambivalent feeling tones, while in the neuroses they
are concealed behind a large part of the symptoms.
Congenital Deficiency and Perversions of Particular Affective

Groups
Congenital deficiency is almost always described as a defect of
the ethical feelings; there is, besides, though very seldom, a defect
of the sexuality with all its affects.
False affective accentuations in the sense of perversions, in which
the instinctive side stands in the foreground (sex impulse, hunger
impulse) are described in the chapter on impulses.*^
Exaggerations and Onesidedness of the Affective Causes,

Morbid Reactions
These disturbances are of fundamental importance for the
neuroses, for the understanding and treatment of abnormal characters,
and for pedagogics, but of lesser importance for special psychiatry,
hence we shall give here only a few suggestions.
Strong affects may lead to disturbances of consciousness in psycho-
pathic persons. The (prison outbreak) and
blind rage of prisoners
oligophrenics, which may last from a few minutes to many hours,
is well known. It is often followed by amnesia. Exaggerated physical
symptoms such as fainting, or vomiting, may accompany the attack
or represent it alone.
The characteristic factor may here show itself in the force of the
momentary affect or in a lack of inhibitions, the latter occurs in
definite dispositions such as manic depressions, alcoholic effects, etc.
When the effect more chronic in psychopathic individuals delusions
is
are easily formed, which disappear with a change of the situation.

A part of the prison psychoses *^ belong here.
Instead of acting forcibly, the affect can inhibit itself and then
leads to stupor wherein thoughts and outer reactions are shut off;
*'
For Affective Disturbances of the Individual Morbid Groups see Symp-
tomatology of the Diseases in special part.
^'Cf. especially Birnbaum: Psychosen mit Wahnbildung und Wahnhaften
Einbildungen bei Degenerativen. Marhold, Halle a. S. 1908.
or the affect alone is suppressed, so that a particularly terrifying

experience is calmly considered and observed but no affect is felt,
as in the cases of Livingstone v^^hen he was attacked by a lion and

Balzy's behavior during an earthquake. In a lesser degree we
observe a kind of indifference in children and psychopaths (belle
indifference des hysteriques). The mental stream may become con-
fused as in making a speech.
Not quite identical with the affective stupor is the embarrass-
ment which is to be conceived in the broadest sense. It is often
only a question of a different attitude, as where it is impossible to
do some'thing consciously which can otherwise be done well more or
lesg automatically, as opening certain locks and similar acts. If an
affect is added, the effect is naturally still stronger. What is known
in one situation is not at one's disposal in the other (Examination
stupor and stairway wit). If a special effort is made to accomplish
something, or when one fears lest he make a failure of it, he is then
sure not to succeed, a mechanism seen in stuttering, bladder control,
impotence, and erythrophobia. As a matter of fact every act which
is more or less automatic, be it psychic or physical, is disturbed
through the interference of the conscious will. As examples we may

mention the common chronic constipation as a result of a psychic
habit to drugs or occupation with the bowels, the complaints of
menstruation, and the difficulties of childbirth.
Stuporous states can become chronic in connection with definite
situations or a definite morbid symptom, also in the face of a certain
teacher or subject where something awkward had occurred. And
yet a pupil who reacts in this manner may appear normal. The
most stupid way to correct it is to bully the patient. On the con-
trary, one must make the effort to remove the affect by kindly ignor-
ing it, or in the more intelligent patients one can establish a different
mental attitude through enlightenment. Inner complexes also act
in the same way. The onanism complex, and not the onanism, con-
tinually prevents the patient from concentrating on other things, so
that he gives the impression of having a poor memory. Depressive
and exalted moods emanate from such complexes. Thus a man is
more homosexually than heterosexuaJly predisposed and becomes
dissatisfied with his married life, but he cannot grasp the situation
in view of his love for his wife with whom he apparently lives happily.
He finally becomes depressed but improves as soon as everything be-
comes clear to him and he adjusts himself to it.
Continuous false attitudes result particularly from an injury to
one's personality through acts which are considered "unjust." Y'oung
people, and even children in the first years can in this way acquire
and forever continue a false attitude towards life.
Thus develops functionally an entirely different type of character,
usually unsocial, who can he differentiated from the congenital type
only through close observation, hut who can he changed hack. Of
diagnostic significance is the existence in many cases of moral
feelings from which one must naturally exclude the mere "weaknesses
of will" resulting from flighty affects. Parents and teachers do
not understand certain reactions of the child and punish him for them.
The child conceives that as an injustice, and assumes a rebellious
attitude. Everything is then viewed under the guise of this complex
and a moral attitude is formed which particidarly fits this purpose
and runs something like the following: ''My father has been unfair
to me, he is to blame for everything. It is only just that I disgrace
him through stealing." Such reflections assume so exclusive an im-
portance that a regard for one's own welfare entirely disappears:
"It serves you right that my hands are frost bitten, it is just
what you wanted" becomes a maxim and cannot be corrected by
ordinary reflection, simply because all the associations become
only half conscious, if at all. It is only by correct treatment,
especially by analysis that such a stubborn individual can be
saved from lasting criminality. A young woman merges into an
"expectation neurosis" to spite her husband, who treated her dis-
gustingly, and throughout her whole life cannot extricate herself
from the disease even after her husband died. To be sure there
were also other important factors which determined the origin
and particularly the special kind of the disease. Little children
often cannot emerge from their spiteful attitude although they are

seemingly willing and the same is true of argumentative adults;
that accounts for the favorable results that are often brought about
by outsiders.
Similar attitudes, though of lesser degree, result in young people
who possess special talents in manual skill, art, or in any other
sphere, but who are forced to learn to occupy themselves with some-
thing else. They are dissatisfied with themselves and the world,
they are incapable of accomplishing things, they show a tendency
for all kinds of neuroses, and are forced to assume a dereistic or
negativistic attitude to the world. The same is the case in people
who wish to go too high. Many dissatisfactions, neuroses and some
psychoses (paranoias) result from a disproportion between aim and
ability. Bumke tells what is quite characteristic, namely, that a
striking number of students who appeal tq him for treatment be-
cause they are no longer capable of mental work think seriously of

qualifying for academic positions.
An unsuccessful separation from the parents has similar results.
Also a former disagreeable experience can result in false attitudes
or a tendency to certain neurotic diseases.
Affects and impulses that cannot be gratified often find spon-
taneously a harmless discharge, or under conscious guidance the
affects and impulses may be utilized for similar activities. Thus
sexual love and the childish impulse associate themselves with ordi-
nary love for mankind and occupy themselves with charity and
nursing the sick (Freud's sublimation). Sometimes they change into
childish exaggerations as seen in the love evinced by old maids for
cats and pups; frequently, however, this does not gratify the original
impulse, especially when the latter is repressed. The sublimation
then manifests itself only in repeated flare-ups of straw fire which
can never cook the soup.
Under other circumstances the affects become stirred up in the
unconscious. Every new similar experience increases the tension;
thus there is on the one hand, an explosion-readiness to certain ex-
periences, and on the other hand, an unconscious affective search for

such processes. A child that has once experienced great anxiety
without understanding it when the experience becomes
correctly, or
repressed by the anxiety, becomes more and more timid; it becomes
sensitized to anxious experiences and peculiarly enough it repeatedly
meets with accidents which stimulate anxiety. Later such a child
becomes neurotic.
The hunger for excitement of some people comes about in this
manner. There are people who must always be doing something,
it matters little whether the situation is of a pleasurable or painful
nature. Sometimes a decided preference is shown for the latter,

they experience "ecstatic pain," martyrlike pleasure, and forever con-
sider themselves unfairly treated. Every occasion is skilfully elabo-
rated into a ''scene;" and their own misfortunes are not only relished
but decidedly more or less instigated and brought to a point. (The
normal prototype is seen in the enjoyment of a tragedy.) The
elaboration is often an inner one; thus any kind of experiences are
misinterpreted in the sense of martyrdom and by some patients also
in the sense of self-aggrandizement. Many of these patients seem
abnormal only under definite conditions or to certain persons, other-
wise their reactions are normal.
.Complex ideas are sometimes mightier than the repressing forces.
One is then pursued by a memory throughout life; any similar ex-
periences cause them to reappear with their entire affective load, or
they are even more or less constantly present in consciousness, domi-
nating the mood and the inner and outer reactions (the dysamnesia
of Cecile Vogt).
Partly congenital and partly determined by complexes is the ex-
aggerated need for change, or the impossibility to tolerate long any
kind of situation. No matter where the person is he is either
"homesick" or in some "mix-up." After a little while every occupa-
tion has something wrong about it. On the one side the normal need
for change is exaggerated, on the other there is a lack of love for
the customary.
A familiar feeling is the impossibility of getting out of one's shell,
or the inability to express oneself, observed in many persons who have
to endure much injustice without being able to defend themselves.
They conceal their feelings, are inclined to secretiveness, and easily
become untruthful despite their good character.
As everywhere else it is especially ambivalent complexes which
become pathogenic in this manner, also situations which render
prominent the negative side of a suggestion or of a tendency. If
one offers sweets to a little child and indicates by tone of voice
or in any other way that it is expected to react to it with pleas-
ure and special thanks, he can be quite certain that the child will
not accept it. It is really only a matter of accident whether the
machine moves backward or forward. He who reacts to a complex
with stealing is often hardly worse than another who responds to
the situation with self-sacrifice.
The difficulty lies less frequently in the events than in the
incompatibility of the characters living together. Let us say that
the husband is a very easy going person while the wife is active and
hungry for excitement. No matter how slight the difficulty is, she
finds the need for making a scene; the more extreme her expressions,
the less the husband is able to get out of himself, which thus only
enhances her affect. This continues until the vicious circle is broken
by some small or big catastrophe.
Both under occasional as well as under repeated or chronic in-
which not only impede the ad-
fluences there result false attitudes
justment but under certain discomforts make it more and more
sensitive. A stimulus accepted as a matter of course causes no
disturbance. Thus if we should be disturbed at home by a person
making a big noise and shaking the chair we are sitting in, any
intellectual work would be impossible, but in similar conditions of
noise and motion in a moving train we might be able to concentrate
on any intellectual work even better than at our writinj^ table. The
baby who cannot yet think that people should be quiet for his sake
adapts himself to any noise, the wife doesn't hear the snoring of the
husband she loves, and the exertions in frames of sport are per-
ceived as enjoyment and recreation despite the fact that it exceeds
by far the "tiring" resulting from work. A great part of the so-
called neurasthenic symptoms and the whole "expectation neurosis"
are based on such attitudes. Depending on the attitude assumed,
one becomes particularly sensitive to events which repeat themselves
or particularly insensitive, a fact which holds true also for material
or moral filth.
A very useful, though, to be sure, as little exhaustive as a sharply
defined classification of reaction types to difficulties, is given by
Kretschmer. The hysteric evades the struggle, the erethic takes
it up and magnifies it, the sensitive individual takes refuge in his
inner self and builds up various forms
of delusions and obsessions,
and the asthenic person sinks into an inactive depression.
Other details concerning morbid affective reactions will be given
later under "Psychopathic Forms of Reactions."
Pathology of Affective Disturbances

The affective anomalies are in the first place a function of the
disposition. The latter is acted upon, on the one hand, by various
reactions which can become distorted into morbid states, and on
the other hand, there are endogenous surface reactions of which the
emotional disturbances of manic depressive insanity are the most
striking examples.
These disturbances seem to correspond to physiological (chemical)
attitudes. It is nevertheless remarkable that many manic depres-
sive patients react with abnormal force to psychic stimuli during
their healthy interval, which leads one to believe that the attacks
of the disease may be put side by side with these psychogenic
fluctuations. Moreover, a small portion of the actual manic depressive
manifestations is dissipated by psychic reasons, and it is known
that there are similar emotional disturbances which do not belong
to this disease and which are put in operation by psychic factors.
The difficulty is undoubtedly solved in the following manner: The
affects like other psychisms reenforce one another; a depression, for
example, unites the depressive associations and inhibits those of a
euphoric tendency; in this way the affect is strengthened and main-
tained. In the same manner it inhibits in the physical sphere, for
example, respiration and digestion, it affects the pulse more un-
favorably, and lets loose the inner secretory processes corresponding
to it, which can again reenforce the affect. The disease causing
agent can attack in any preferred place of these two circular con-
necting causes. Let us assume that in the manic depressive patient
there exists a special lability in the functions of the endocrine glands.
The fluctuations of the glandular activities may be conditioned by
causes existing outside of them; but, as probably happens in the
periodicity, this function can also become too easily exhausted and
then again functionate too strongly. In both cases we have the usual
manic depressive attack which is conditioned "from inside to outside"
but similarly an attack results when the glands react too strongly
to an exogenously (psychic) determined depression.
Most of the emotional disturbances of epileptics and of some oligo-
phrenics are also conditioned by some chemism. It is nevertheless a
striking fact that precisely the oligophrenics with brain lesions and
particularly patients suffering brain injuries, show a tendency to
produce endogenous emotional disturbances which are mostly, though
not exclusively, of an irritable nature. The continuous irritability
seen in those who have brain lesions is also anatomically determined.
It is not absolutely certain,but according to many obserAâtions it
is probable that there are also periodic emotional disturbances of a
psychogenic nature analogous to the lasting attitudes mentioned above.

Any kind of complex, let us say, dissatisfaction with parents, be-
comes half or completely repressed so that the child cannot fully
account to himself for his actions. But the need for abreaction finds
some vent through excitements or emotional disturbances and is
then followed by a calm period. By and by, however, the tension
accumulates again only to express itself in the same manner without
any new cause, or through some ordinary occasion.
The lability of organic patients is but a secondary manifesta-
tion of the general cerebral disturbance. For we note a slight per-
severance of the psychisms even in the spheres of memory, and the
limitation of the associations is undoubtedly responsible for the fact
that only actual situations are reacted to. In epilepsy, on the con-
trary, all the other psychisms run a slow course; the getting away
from an idea is just as difficult as the alteration of an affect.
The tendency to depression in senile patients is not adequately

explained by the suggestion that depressions increase with age and
especially with general circulatory disturbances. Also the euphoria
of paresis is as little explained as the rare paretic depressions.
The morbid reactions require no special explanation, as they spring
from normal mechanisms, and act in an exaggerated and one-sided
GENERAL PSYCIIOPATHOLOGY 133
manner only in conHcquenco of extraordinary occasions or of a

disposition deviating from the normal.
8. DISTURBANCES OF ATTENTION
The pathology of attention is very complicated because its effects
are strongly by the other functions.
influenced Exhaustion and
many morbid states weaken the faculty of concentration. The scope
of attention is determined by the amount of associations that may
occur at the same time; it is consequently lowered in organic patients.
The exaggerated readiness of psychic processes in manic cases weakens
the inhibiting effect of the effort of tenacity upon distracting in-
fluences. The lack of tenacity in organic cases is sometimes irregu-
larly over-compensated by torpid retardation of the psychic processes,
so that secondary hypo-vigility goes hand in hand with lack of
tenacity. In twilight states, toxemias and similar states, where the
mental trend becomes quite unintelligible, one can hardly still speak
of attention, even where distinct affects are present, because the inner
and outer strivings may become disconnected. The following remarks,
therefore, emphasize only the most important facts in a somewhat
schematical and simpler manner.
Ceteris paribiLS attention varies with the affects. When the latter
are labile, or when the same interest is given to the most dissimilar
ideas, as raising all ideas upwards in the manic states, and lower-
ing them to zero in cases of indifference and lack of comprehension,
the vigility and the distractibility of attention naturally are quite
marked. Tenacity need not here be diminished, because even with-
out distractibility the subject may be adhered to; to be sure, there
are few situations in which outer and inner distractibilities are absent
for any length of time.
If the affects are stable, the tenacity also runs high.
In Schizophrenia and exceptional states of epilepsy, more seldom
in neurasthenia and other affections, we sometimes find a strange
mixture of exaggerated and slight distractibility. The patients react
with difficulty to questions and other stimuli, but they react to many
accidental sensory impressions such as the striking of the clock, the
entrance of a person, a word not addressed to them, or to any object
which happens to strike their eyes. But the epileptics and some schizo-
phrenics will then regularly return to their former themes.
The concentration depends mainly upon the strength of the af-
fectivity, yet in labile affects it is usually insufficient.
Whether tenacity is good or not in weak affects and correspond-
ing slight depends upon the accompanying circum-
concentration
stances. An apathetic can concentrate for half a
schizophrenic
day all his small strength on a little thread which he holds in his
hand. On the other hand, he may be diverted by every trifle, be-
cause no interest to speak of restrains him. Hypotenacity, combined
with hypovigility, is a usual manifestation where affects and in-
telligence are low, as in clouded states, apathetic imbecility, and

other cases.
Hypotenacity, without real hypovigility, is found in Aprosexia;
there is an inability to concentrate one's thoughts in reading, for
instance, even for a short time. This symptom, which is not found
very frequently, occurs in neurasthenia, and in impeded nasal breath-
ing as a result of adenoids.
Vigility and tenacity are lowered in Chorea Minor, also in some
cases of torpid imbecility, although here the genetic factors are
quite different.
A rapid "exhaustion" of attention can be observed in many organic
cases, especially in those with coarse brain lesions, also sometimes
in schizophrenics during the acute stages. On the other hand, it often
takes organic patients a longer time to concentrate their attention
on the very subject desired. It is for this reason that perception
experiments with such cases turn out very badly at first, but after
some time the results are betterj until the exhaustion reappears and
the patients again do badly.
The scope of attention is diminished in organic cases and in oligo-
phrenics because of a restriction of associations, and in melancholic
and paranoid patients as a result of one-sided interest, and in epileptics
as a result of both factors. In all forms of paranoia or paranoid
states we also have as an important symptom the systematized
vigility, the morbid association readiness for those events which might
be connected with their delusions.^^
In organic patients, the habitual attention is earlier and more
strongly disturbed than the maximal attention. The patients, for
instance, may seem completely normal as to attention during a
clinical demonstration, but at the same time they are disoriented
in the ward where they have been for weeks, they cannot locate
their bedroom or their bed, because they do not register anything
that happens about, and even to them, if they have no special reason
for being attentive. And what is more, the memory and the compre-
hensive functions of orientation may still be adequate in these cases,
so that the mistake can safely be ascribed to the faculty of attention.
**
Cf. Delusions of reference, p. 94.
The patients observe, as it were, nothing, unless attention is forced

upon them through some circumstance, then they behave, however, in
quite a normal way. This teaches us that intensity, at least, of maxi-
mal attention can be good, in spite of the markedly diminished field
of associations.
Tenacity of attention in organic cases is mostly lowered; the
pa>tientscannot continuously occupy themselves with one thing; they
digress and tire simultaneously, very quickly. But the same patients
find it also difficult to transfer their thoughts to another subject
offered to them. They evincesame time hypotenacity and
at the
(secondary) hypovigility In the manic stages of
of attention.
paresis, hypovigility may be hidden by the distractibility of the
flight of ideas, yet it can usually be demonstrated through examina-
tion, for the patients after discussing their personal affairs cannot
quickly answer a question about their school-knowledge, nor are they

even able to understand it correctly, and this happens even where the
psychic processes in general function very quickly. The excited states
of presbyophrenia can also cause an over-compensation of hypo-
vigility.
In the schizophrenics, the relation of active and passive atten-
tion is the reverse to that of the organics. They register excellently
what is going on around them, even if they do not pay any special
attention to it; but if they should have to concentrate their atten-
tion, they could not succeed, sometimes they are hindered by block-
ings and at the same time they often cannot hold a subject.
In some cases of schizophrenias, especially in crowding of thought,
in fatigue, in hallucinations and delusions, in phobias and other obses-
sions, and in the pathological readiness for association, the direction
of attention is obsessive.
In ordinary fatigue, the power of concentration and tenacity are
usually very much diminished, whereas the distractibility seems to
be enhanced in varying ways.
There is a tendency to explain many other manifestations on the
basis of disturbances of attention, and as a deficiency of attention
may be responsible for all sorts of stupidities, such deductions
can be easily constructed, but just for these reasons most of these
explanations have no scientific value.
9. MORBID SUGGESTIBILITY
A total lack of suggestibility does not perhaps occur except in such
patients who evince an utter lack of comprehension and who no longer
react to stimuli. A marked diminution of suggestibility we observe
occasionally in imbeciles, who are then naturally incapable of any
training. Schizophrenic patients are often little or not at all re-
sponsive to direct suggestions, but in most cases they still react very
slightly to the general attitude of their environment. Wherever
individual groups of affects are lacking, suggestion in the corre-
sponding sense is naturally impossible. Moral idiots cannot be in-
fluenced in a moral sense, or irreligious people in a religious sense.
Paretic patients in a manic state who look at the good side of every-
thing and accentuate it with a feeling of happiness can hardly be
brought to accept a sad situation.
The exaggerations of suggestibility are more important. We can
produce it experimentally in a state of hypnosis. Many people are
by nature as susceptible to all influences as a soft piece of dough.
Fatigue and emotional experiences show a temporary disposition for
suggestibility. Patients in manic states or those suffering from organic
disturbances as well as alcoholics are easily influenced by suggestions.
Just as suggestibility enhanced by the lability or resonance of
is
the affects so it is also through any decrease in the

heightened
critical faculty which normally counteracts suggestions. All things
being equal, the more thoughtless a person, the more suggestible
he is.
Morbid suggestibility may lead to induced insanity, also to psychic

and neurotic epidemics, to participations in crimes, and similar acts.
Hand in hand with positive suggestibility, there is in most cases
also an increase in the negative suggestibility. Like children, senile
patients are now wilful, and now open to the most stupid prompt-
ings. Paranoid patients allow themselves to be easily fooled by
people who have their confidence, whereas they are absolutely inacces-
sible to other persons. In schizophrenic cases we often find com-
mand automatism and echopraxia, that is, high degrees of suggestibility
combined with a pronounced negativism.
The so-called auto-suggestion is an important source of morbid
states. No neuroses are possible without its cooperation ("Imaginary"
diseases). Thus a girl in a street car sees an eczematous eruption
on the hand of another passenger and becomes very excited because
it unconsciously touched her "complex" referring to her paretic or
luetic father; she then develops an eczema-like eruption in the same
place as the passenger.^" A traumatic patient fears that he can no
longer support his family and hopes to assure his existence through
^
Friedman u. Kohnstamm, Zur Pathogenese u. Psychotherapie bei Basedow-
scher Krankheit, Zeitschrift f. d. ges. Neur. u. Psych. Or. 23, 1914.
.
a pension. He observes himself anxiously and by this very means

creates the necessary morbid symptoms. A girl fears lest her men-
and thus causes i temporary amenorrlifjea.
strual period fail to appear,
To be sure, auto-suggestion may have the opposite favorable effect
which is curative in nature. These examples show that positive and
negative suggestions are really not true opposites, and that both
together are nothing but emotional effects.
10. DISTURBANCES OF PERSONALITY

Every mental disorder changes the personality in some sense if
not altogether. The manic patients become reckless and actively
exaggerated, the paranoid and in most cases also the paranoiac pa-
tients lose their general interests in life and live only in their de-
lusions, the epileptic concentrates on his physical well-being and his
petty affairs, the intelligent person becomes stupid and thoughtless
as a result of a dementing process, and so on.
The inner disturbances of personality are not as comprehensible.
Thus an ordinary citizen imagines himself an emperor. "What he
knows of the Emperor, he feels as part of his person: appersonation.
Even hypochondriacal ideas can be acquired in this way; thus, the
medical student in his first term of clinical experience, hearing a vi\-id
description of some disease of the heart and seeing it demonstrated in
one or several patients, becomes so deeply impressed that under cer-
tain conditions he feels that he has the same heart trouble (Morbus
Medicorum).
Less frequently the personality loses some of its component parts.
It naturally happens that certain events of one's life are forgotten;
this is especially true in schizophrenic patients who forget a part
of their disagreeable experiences, and often deny bona fide actions,
the commitment of which they later regret. This does not, however,
concern things that belong to the essence of the personality. On
the other hand, the most important components are often replaced by
others; thus John Smith becomes President Harding, or Christ (see
below)
A special type of disturbance of personality is the alternating
personality, alsoknown as dual consciousness. Let us consider a
hysterical woman who until now has lived a mediocre existence. For
some known or unknown reason she falls into a hysterical sleep,
and on awakening she has forgotten her entire previous existence;
she does not know who she is, where she has lived until now, and
who the persons are whom she sees around her. Notwithstanding
this change, the ordinary faculties of walking, speaking, eating, the
use of clothes and other things are usually transferred to the new state
("etat second"). Whatever the patient needs for her intercourse with
other people she learns very quickly. Her character, too, undergoes
a change; formerly a serious-minded now becomes frivolous
girl, she
and pleasure-seeking. After some time, she again merges into a state
of sleep, and on awakening the patient is back in her first state.
She has no realization of the intervening time; all that she remembers
is that she went to sleep, and has now awakened as usual. Such
changed states may appear alternately for years. While in the first
state the patient only remembers the former first states and when
in the second she always recalls only those of the second series.
More frequently, however, it seems that in the second state the
patient can recall the first (normal) series, but while in the first
state she cannot recall the second (morbid) series. It may also hap-
pen that eventually the second state will become permanent, and this
way cause a transformation of the personality. In quite rare cases
there may be an alternation of many such states, each with its very
definite character and special memory group (personality) as many ;
as twelve have been observed. As a matter of fact, cases of pure

dual personalities are very rare. Yet their theoretical significance
is very great, for they show what marked changes can be brought
about by a systematic elimination or intercalation of association paths.

It is not alone in hysteria that one finds an arrangement of differ-
ent personalities one succeeding the other; through similar mechanisms
schizophrenia produces different personalities existing side by side.
As a matter of fact, there is no need of delving into those rare though
most demonstrable hysterical cases; we can produce the very same
phenomena, experimentally, through hypnotic suggestion, and we
also know that in the ordinary hysterical twilight states the memory
of former attacks, concerning which the patient shows an amnesia
in her normal state, can be retained or can be aroused by suggestion.
The splitting off of parts of a personality in transitivism pro-
ceeds in a different manner; here the patient's own experiences become
detached from him, and are ascribed to another person. A patient;
for example, sees a terrifying image and screams aloud; but he
then imagines that the apparition did the screaming. A woman has
an operation on her toe, during the long drawn out delirium of the
narcosis she continually asks the nurse to look after her bed-neighbor,
because the latter is having bad pains in her toe. A person dreams
during the night before he has diarrhoea that pamphlets which he
has to send out suffer from diarrhoea. It is quite common to displace
feeling which we have ourselves in our dreams to other persons.

Transitivism is an almost common occurrence in schizophrenia; the
patients are convinced that the voices which they hear are also heard
by others in the same way; they frequently ascribe their own
actions to others; thus, if they read something, it is really done by
others; their thoughts are thought by others, and so on.
A strange disturbance of personality is de-personalization, in which
the patients have lost the definite idea of their ego. They seem
quite different to themselves, and feel that they must look in the
mirror to see if they are still themselves, and even then their own
images appear strange. This disturbance manifests itself especially
through the fact that the patients do not feel their own will power
and strivings, they feel like automatons; sometimes they are indiffer-
ent to it, but in most cases they perceive this state as extremely un-
pleasant. This syndrome appears in schizophrenia, perhaps also in
neurasthenic-like states of psychopathic patients, and in a less pro-
nounced degree it is also observed transitionally in epileptic twilight
states. It is often connected with the analogous feelings of strange-
ness in regard to the outside world.
In schizophrenia one sees a great many forms of transformations
of personality of which I only want to mention a few types. The
patients suddenly imagine that they are Napoleon, and some enter-
tain the idea without giving up their past life; it is merely an
addition to their past life. In other cases they shut off at least every-
thing incompatible with the delusion; thus, those who have grandiose
ideas state they were not born in the locality in question, they did
not go to school there, but in some mysterious way circumstances
forcedthem to play the part of John Smith for some time, but now
they want to re-establish their sovereign authority over Europe. In
other cases, the former personality ceases to exist; sometimes, but
by no means always, they have interwoven the past of Napoleon with
the present of their momentary delusional personality. Others have
become Christ, or even God. The latter mechanism is not a rare
occurrence in paretic patients, but in most cases it exerts no in-
fluence whatever on their actions, whereas schizophrenic patients
sometimes may act in accordance with the change of personality.
When I expressed astonishment that he knew the whole Bible by
heart, such a god said to me that there was nothing unusual about
it, as he had written it himself; and to my remark that it was
strange that we perceived nothing of his omniscient spirit, he an-
swered that he had sent out his spirit among mankind, and now so
little was left for him that he had come into the asylum, but that
he could recall his spirit at any moment, only he would not do so
out of compassion for poor mankind. Other patients imagine them-
selves transformed into animals and even into things, and yet they
usually do not adhere to one idea. Just as a patient can be the
Pope, the Emperor, the Sultan, and eventually God in one person,
he can also be a pig and a horse. Nevertheless the patients rarely
follow up the logic to act accordingly, as, for instance, to bark like
a dog when they profess to be a dog. Although they refuse to admit
the truth, they behave as if the expression is only to be taken
symbolically, in the same way perhaps as when a man is insultingly

called a pig.
an ordinary occurrence to see schizophrenic patients
It is quite
identify themselves in themost illogical way with people whom they
love or admire. Under certain conditions, and in a certain sense,
they are their beloved, they had the same experience as they, and
they play their beloved's part. A non-schizophrenic patient of v.
Krafft-Ebing, who loved only limping women, could not resist the
impulse to imitate such a limping woman.
Some schizophrenics have altogether lost their personality. For-
merly they have been so-and-so, but now they are somebody else,
and their former personality may be in some other person. Under
such circumstances it may happen that they speak of themselves in
the third person, for they have the feeling that they are no longer
the person whom they have designated as "I."
Temporary transformations of the person into another, as, for
example, into potentates or saints, occur occasionally in the different
twilight states.
Nowadays there is much talk about 'the preservation or annihila-
tion of the personality. Kraepelin's paraphrenics are supposed to
differfrom schizophrenia, the arteriosclerotic and luetic psychoses
from simple senile dementia, and the latter from the most disturbed
paretics, in the fact that the personality is fairly well, or better pre-
served. By that we understand the active continuation of the hitherto
existing strivings and aims of action, as well as of the more important
characteristics in general. In organic diseases, where the personality
is not much injured, which is especially the case in arteriosclerotic
insanity, there is surely no lack of affective changes in the sense of
lability, knows something about it,
or irritability, but the patient
and he even often endeavors to combat Having been an
his faults.
honest man he does not now turn into a scoundrel; when he is no
longer able to support his family he perceives it painfully, and his
external appearance remains relatively good, in so far as his mental
clearness is not disturbed. That accounts for the fact that these
people are in no immediate need of asylum treatment, and when they
are sent there it is frequently only in consequence of a single special
circumstance, such as a danger of suicide, or confusion.
The schizophrenic disturbance of personality is much deeper and
more far reaching. Even when the organic patient changes into a
different person and his strivings often change only too much, yet
what he feels and strives for in a single moment is the expression
of his whole actual psyche. On
the other hand, the schizophrenic
may at the same time something contradictory, and do some-
strive for
thing that he has not desired and even despised. His personality can
divide itself; now he acts and thinks like a great man, now like a
scholar, or in another manner, and his hallucinations and delusions
then also correspond to it. There are forever different strivings,
which embody themselves in such personalities.^^ Very frequently
the direction from and to a person is no longer distinguished. A
paranoid patient fears in her depression that she is being harmed;
she is then commanded by the voices to help others instead of that
help should be given to her as might have been expected. Everyday
experience shows that both ideas are identical to the patient and
that it is not necessary to add a logical connecting link. A persecuted
patient wants to become a professor, but he complains that people
want to force him to be a professor.
In severe cases of schizophrenia, a high degree of disintegration of
personality results because the uniform striving and the uniform
memory complex become destroyed; the patients babble and show
no coherence in thoughts and wishes, indeed the borderline between
their own person and the environment is blurred. As in appersona-
tion and in transitivism concepts which do not belong to the person
become connected with him, and vice versa. Thus the strongest as-
sociations may finally detach themselves, while any other ideas may
become associated with the person, if in such cases one can still speak
of a person at all.
In general, the schizophrenic personality suffers in the follow-

ing different ways: Through dementia, the restrictions or perversities
of the instinctive through the disturbance of the uniform direction
life,
of the striving and acting, and the disturbances of will which force
schizophrenics into actions that they do not strive for at all.
In most of the disturbances of personality one deals w'ith a split-
ting in the direction of the affective needs, that is to say, with simple
emotional effects which in themselves are verj^ violent, or become
-
Cf. Complexes, pp. 35-36.
overpowering in a morbid soil; this is seen, for instance, in paresis,
where, owing to the restriction of associations, the wish to be God
Almighty is put into reality without any further ado, also in schizo-
phrenia particularly after the structure of associations has already
become loosened; in the latter cases the complexes can actually
acquire sub-personalities with some sort of independence within the
psyche. Depending on the circumstances the patient is this or that
personality, or,what is still more frequent, he hears in the voices,
now the expression of this complex (the wish to be a Prince) and at ,
another time that of another complex (to be condemned as an onanist).

I am not sufficiently clear about depersonalization, because cases
common. In part we probably
giving reliable information are not very
have to deal with the same process which we see in the melancholic
patients, to whom external things appear strange, perhaps because the
feeling components are so strongly falsified. But if the patients are
not conscious of their own volition-impulse it must be due to the
blocking of an inner feeling, the mechanism and causes of which is
not just clear.
11. DISTURBANCES OF CENTRIFUGAL FUNCTIONS

Actions as the final link in the chain of psychic processes are
naturally inadequate to the situations if the sensations, deliberations
or feelings upon which they depend are inadequate. He who is con-
trolled by false perceptions, and imagines that robbers are breaking
in when his nurses are coming, will defend himself. Some halluci-
nations influence the patient directly, and often in a forceful way;
he has to act in the sense of the hallucinations even if he realizes
that he does thereby something detrimental to himself and to others.
This mode of action does not always need the form of commands.
Thus, a periodic patient named Mantel, who was locked in his room,
repeatedly heard the words: "Mantel, thou strong hero." Whereupon
he reacted by demolishing his room, to show his annoyers that he
was really so strong. To be sure, the hallucinations instigate only
those actions for which a tendency already exists; but this does not
need to be the tendency of the conscious personality; indeed, it may
even be incompatible with it. At the same time there are hallucina-
tions foi the obedience of which there is little or hardly any impulse,
and in later stages of schizophrenia the patients regularly refuse to
obey their hallucinations, in spite of the fact that they believe in them
as strongly as ever.
The so-called hallucinatory excitements in schizophrenia are also
GENERAL PSYCHOPATHOLOCiY 143
worthy of mention; here, under the impresnion (jf false perceptions,

the patients suddenly become abusive, strike blindly, or commit any
other acts of violence. To be sure, in most cases one does not know
to what extent the hallucinations are only a part of the symptoms of
the whole excitable action, and to what extent they are the cause
of the violent outburst.
If thinking is disturbed so that it sets incorrect aims toward action,
then the acts also are false. He who entertains the delusion that
people want to poison him will in most cases react to it, which is quite
correct from his viewpoint, but pathological from the observer's. An
aimless or feeble-minded thinking will condition aimless or feeble-
minded actions. If the thinking of the psychopathic and insane devi-
ates from the average thinking, it means in most cases a deterioration
of quality ; the actions of the real insane persons are nearly always of
inferior quality or of negative value. In exceptional cases, however,
and especially mere psychopaths the anomaly leads to new values. ^^
in
Action is for the most part influenced by afjectivity, if one at least
agrees with us when we designate the force and direction of the im-
pulses, or of the "will," as partial manifestations of the affects. He
who ishappy, sad or furious, will react accordingly. Fear can make
a person motionless and rigid or limp, it can urge him to aimless
flight, or merely to a restless manifestation of the affect, such as rest-
lessly walking to and fro, or to brutal acts of violence. The last named
are especially striking when motility is otherwise practically absent
and the anxious or depressed patient suddenly gives vent to his feeling
by destroying some object or even by committing a murder. Such
reactions to unbearable tension are designated as raptus.^^ The ab-
sence of ethical feelings brings to the surface anti-social actions.
Lability of feelings and emotivity make the actions unsteady and
capricious. Absence of weakness of the same
feelings in general or
diminishes the impulses, and makes them weak. The expression
"Weakness of Will" designates three totally different things: (1) A
lack of will impulses due to a weakness of the affect-s, or a lack of
steam pressure in the engine, abulia as a result of apathy. (2) Incon-
sistency of the aims in the face of very vivid, but too labile affects,
which make its bearer dependent on outer influences; a slight push
causes the engine to run backwards too easily, when it should go for-
ward, which is due to the fact that the direction-switch is too easily
movable. Frivolous people and those who are unable to act in
"Comp. remarks on Genius, p. 171.

" There is also a raptus in schizophrenic patients which is merely an execution
of sudden impulses without affective tension.
accordance with their own resolutions are congenitally weak-willed in
this sense; manic and organic patients become so through their illness.
This kind of weakness of will can also be ascribed to an exaggerated
suggestibility, which only partly coincides with the lability of affects.
(3) Incapacity to make decisions through counter reflections and im-
pulses in persons who are too conscientious and too deliberate in
everything, and in those who are in a depressed state.
Wherever one does not observe any, or very slight expressions of
will, one speaks of stupor; in such cases thinking is usually at a low
ebb; indeed, in some states the disturbance of thought as such may be
in the foreground as in the emotional stupor of imbeciles. Stupor is
no uniform syndrome, but an outer form of manifestation of the fol-

lowing different states: maximal apathy, inhibitions, obstructions, over-
powering through fright or anxiety, and cerebral torpor of any kind.
Thus we find stupor, especially in schizophrenia where apathy, block-
ings, inhibitions, and sometimes cerebral torpor appear together, fur-
thermore in epilepsy, in organic diseases, and in manic-depressive inhi-
bitions. Nevertheless, in regard to the latter, it must be observed that
one does not like to call melancholic inhibitions stupor, if, as is usual,
they are distinctly connected with signs of severe physical pain.
Melancholia attonita, as it was formerly called, is usually a catatonia,
with or without depression. Stupor resulting from strong affects
(emotional stupor) we find in its highest development especially in
hysteria, and to a lesser degree very frequently in forms of congenital
feeble-mindedness.
A hyper-function of the will in the sense of special strength is
naturally difficult to establish, because a person seems to us the

healthier, the stronger his will is. Yet, in hysterical and other psycho-
pathic cases we sometimes see a force of impulse, of endurance, and
capacity to bear pain, which far exceeds the normal. Also schizo-
phrenic patients sometimes develop a special energy or will, as, for
instance, when they pull out their own teeth, squeeze out one of their
eyes, or do something similar without being analgesic. The dissimu-
lation of symptoms of disease, especially in melancholies, points to
an enormous force of will. of manic patients who
The occupation urge
constantly want to do all and accomplish much has
sorts of things
also been regarded as a hyperfunction of will. We also mention here
the hyperkineses of many catatonic patients (see below) which in
everything else are principally separated from them.
A morbid facility of the capacity to make decisions is observed in
manic patients and under mild alcoholic stimulation. Also in affects
which compel actions such as fury, or fear, but here it is naturally
;
one-sided, acting only in the direction of the affect; every idea which
has a centrifugal component leads straight to action. The possibility
of an accurate reflection is hereby always diminished; the actions
become precipitated. If reflection is primarily inhibited the reverse
is the case, all things being equal; any kind of stimulus leads to action
more easily and more quickly.
The ability to make decisions is primarily badly impaired in
melancholic states, secondarily it is still more diminished through the

feeling of insufficient reflection and especially through the general
unpleasant accentuation of all the possible objective ideas. If the
patient is inclined to go in the open air he feels it as something too
terrible; if he thinks of remaining in the room, that too, seems just
as unbearable. In apathy no decision can be taken, because the im-
pulse is lacking; the same is the case in torpor, where all psychic
processes are low. In states of obstruction, as long as it exists, the
physical processes are interrupted either altogether or especially in the
direction of the decision, and nothing happens. But there can also be
too much thinking. Whoever inclines to take into account every
imaginable possibility can hardly arrive at a conclusion. A certain
onesidedness is necessary in action; one must give up advantages in
big or small matters and must be able to risk something, if one wants
to act at the right time and with the necessary force. The ambivalence
of the feeling tone an obstacle to the decision. If one loves and
^* is
hates at the same time without summing up the positive and negative
feelings into a unified difference, one is torn to both sides and does not
get any results even in deciding. The so-called psychomotor ex-
citements and inhibitions naturally concern the whole psyche; in any
case they are not strictly confined to motility, but distinctly influence
also the need for action, the ability to make decisions, and the facility
of the transition of the excitement over the true centrifugal paths.
The manic pressure activity (the urge to occupy oneself) expresses
itself inthe fact that the patients can never permit themselves to
rest; something has to happen all the time. In milder cases it is
merely a quantitative increase of action that is observed, which can
also be accomplished by a normal person, such as an increase of busi-
ness activity or similar acts in more severe cases it comes to excesses
;
thus one notes a thoughtlessness in all spheres of action, and finally

there is a destruction of objects and a building up of new combina-
tions from the material acquired; there is a constant smearing,
screaming, jumping and similar acts. Taken singly, the aims usually
change very quickly under these conditions; nothing is finished, and
" Cf. p. 125.
.

even in mild cases one notes a lack of perseverance in the business
enterprises ofmanic patients. The pressure activity is naturally also
disburdened through talking. The patients are very talkative and
they can not really get away from their talking which becomes more
and more incoherent {LogorrhoBa)
The depressive inhibition of action causes actions to be avoided as
far as possible, in more severe cases altogether, or if motions and
actions still exist, they represent the monotonous discharge of the
dominating affect, especially that of anxiety.
The highest degree of inhibition of motion is designated as attonity.
For long periods the patients really make no active movement. They
have to be dressed and undressed like puppets, they have to be fed
with a spoon or even with the tube, their saliva is not swallowed, but
drools from the corners of their mouths, and even the movements of
the eyelids can stop. Such states nearly always belong to the schizo-
phrenic stupor, especially of the depressive type.
There exists also a simple schizophrenic akinesis, which we cannot
at present very well refer to other disturbances because the accom-
panying symptoms seem insufficiently developed. In contrast to this
we have the schizophrenic hyperkinesis where the patients are in con-
stant motion, but yet do not seem to "act." Without any apparent
reason, as far as we can learn, without any motive known to them-
selves, they are actively violent, they are destructive, they throw
themselves or only their limbs in the air, they play tricks, etc. Never-
theless, both subjectively and objectively the action appears to be in-
tended: it is a psychic motion impulse without motive, one might say,
a kind of convulsion of psychomotility (but not at all a motor spasm
in the usual sense). The mere pressure motion shovM he distinctly
differentiated from the pressure occupation of the manic patients
which always has a meaning. The attempt has been made to classify
also verbigeration as an analogous "cramp of the speech centre," but
it is not particularly often combined with hyperkinesis.
The concept of jactation refers more to the outward appearance.

Here also we deal with mere motions, which are especially weak; at
most they represent rudiments of actions and have quite different
causes. Under certain conditions hyperkinetic states in the sense just
now described may be called jactations; the term may also be applied
to agitation caused by fear or other uncomfortable feelings, or the
tossing about in pain; but the concept corresponds best to the move-
ments in cerebral irritations, as seen in meningitis or acute delirium.
In schizophrenia there is sometimes a motor parafunction which
actually calls to mind apraxia, but at all events it is not genetically
GENERAL PSYCHOPATIIOLOGY 147
analogous to the organic syndrome of this name; it resembles more the

opposite actions produced during shock or distraction: Thus, the
patient wants to put the spoon into the phice, but with uncertain move-
ments he takes it in a strange way first in one hand, then in the other,
where he turns it around, until at last he places it on his knee; or
instead of the spoon he grasps anything else which happens to be at
hand. When walking, his legs move in an uncertain way, in various
long steps, not exactly towards the goal. Kraepelin grouped analogous
disturbances of a lighter grade under the term: "loss of gracefulness."
As the patient is simultaneously moved by different feelings, and as
they are badly suited to the ideas, all actions often appear unreal,
artificial, and affected, and as the associations of ideas also in regard
to the carrying out of the movements do not proceed in usual paths,

they acquire something of the bizarre.''^
Sometimes movements, that is, actions, become stereotyped, in
which case quite different mechanisms may come into play. Catatonic
patients sometimes cannot get through with a movement manifoldly
repeated, such as wiping the face, or scooping up their soup, or they
do not think of stopping even after they have finished these acts. A
strong accompanying affect can easily stereotype an action which then
continues to repeat itself without any voluntary effort on the part of
the patients. In the course of time, it generally becomes more or less
shortened in form, or it changes in regard to place. Thus an original
onanistic movement of the pelvis may finally change into a shaking of
the head. In this, and in still other ways stereotyped movements
originate in catatonic patients, which often last for decades and seem
absurd to the patient as well as to the observer. Customary acts may
undergo changes which then become stereotyped. For example, the
patient taps seven times on his coat at every button he is about to
close; he shakes hands in quite a strange way {Variation stereotypes,
mannerisms) .
There are still other mannerisms besides the variation stereotypes

of which the following may be mentioned: independent clownish ges-
tures, spreading out of fingers, also bizarre expressions of every de-
scription, exaggerated style of dress and hair, caricatured elegance and
finally morbid expressions of affects, exaggerated pathos, and self-
bad
satisfied attitude; in short, the patient evinces all the faults of a
actor. As many show an indication of these changes at puberty, an
attempt was made to regard them as symptoms of puberty, which were
fixed and exaggerated by the disease.
When language becomes stereotyped it is called verbigeration.
" Cf. below, "mannerisms."
Here quite senseless words and sentences, at least for the actual situa-
tion, are constantly repeated, often in a striking tone which is also
stereotyped.
Besides the stereotypes of motion there are those of posture, the
patients always assuming exactly the same position, and of place;
they want to sit, or stand, or walk always in the same place.^''
The stereotypes, in the sense amplified so far, belong to the cata-

tonic symptoms, and outside of schizophrenia occur perhaps also in
organic patients; but it is not at all certain that they are then geneti-
cally of the same value. In any case the perseveration in the organic
patients,which we see most typically in coarse brain lesions, especially
in aphasic patients, is something quite different from stereotypes. The
patients cannot rid themselves of a word which they have just heard,
or which they have just said, and repeat it constantly when they wish
to say something else. And even when the patients execute a simple
action, such as wishing merely to think of something, this impulse may
under certain conditions proceed against their will in the path of the
preceding action, or in the one thought of immediately before.
Other stereotype-like manifestations are the homogeneous actions,
which some epileptic patients perform in post-epileptic twilight states,
the repetitions of terrifying experiences through hallucinations, and
(mostly abbreviated) actions in the twilight states of the hysterical
patients. The manifestation of a lasting strong affect, like the stereo-
typed screaming or wailing of depressed organic patients, the tics,
some actions which have become automatic, and the movements of
idiots,
all these movements which outwardly resemble the schizo-
phrenic stereotypes have quite a different genesis and meaning.

Parafunctions of the will attach themselves mainly to the so-called
impulses. The nutrition-impulse has been stunted in the cultural being
who rarely feels real hunger, and when he wants to starve himself to
death he is forcibly fed. This impulse is also very indirectly satisfied,
in so far as one learns to write at the age of six, in order to earn his
living from ten to twenty years later. Even the impulse of self-preser-
vation in general is no longer at its height with us, either with regard
to the individual, or his family, or his race. The suicide-impulse,

which under simpler circumstances very rarely occurs even in patho-
logical conditions, has become a calamity in our asylums. The sex
impulse has been preserved only in some measure of its original form,
and is pushed back by culture in different ways, such as through
chastity, monogamy, asceticism, and birth control. But this impulse
breaks through with elemental force and creates in the individual those
'"'
For more details Cf chapter on Schizophrenia,
.
inner conflicts whicii mostly become pathogenic. Preserved is tiie
ethical or the altruistic impulse, although just now it is being subjected

to a certain transvaluation. In place of the primary impulses there
are others, which are particularly active, such as the impulse for
knowledge, and tend more towards the preservation of civilization
than life.
The morbid disturbances of the nutrition-impuhe are not so im-
portant in psychiatry. Beside excessive gluttony of the paretic and
idiots, we and in catatonics a peculiar lack of
find in depressions
appetite; indeed there an aversion to eating and drinking resulting
is
in a total abstinence for any length of time. Besides these, nervous

patients evince peculiar cravings (picae) and schizophrenics a ten-
,
dency to swallow all kinds of things, even their own excrement (copro-
phagia), which is sometimes accompanied by gustatory enjoyment and
sometimes not.
The sex-impulse has a special pathology, which will be dealt with
in the special psychiatry. The ethical impulse varies constitutionally
from the "genius of altruism" to the moral idiot, who is devoid of
all altruistic feelings.
The expression "impulse" has quite a different meaning, if one
speaks of "morbid impulses." In most cases this word refers to the

impulses for actions, which are accomplished unexpectedly, without
real reflection or with inconsistent reflection, or without the assent
of the whole personality. Such actions are often distinguished by
and regardlessness of the interests of others,
violence, hastiness, skill,
as well as of their own. But even under the name of impulsive actions,
one includes chiefly different symptoms of various grades. Thus one
speaks of the morbid impulse to set fire to places {Pijrornania) of ,
the stealing impulse {Kleptomania), the murder impulse and similar

pathological states. These disturbances will be described later on under
the heading of "Impulsive Insanity."
All impulsive actions have one thing in common, namely, they are
carried out without the cooperation of reflection and aimful willing.
The expression "Impidsive Actions" expresses only a part of the
same thing, that is, it refers to various indefinable kinds of actions
carried out suddenly and without proper deliberation. This may be
in the form of incomprehensible "afTective-actions" in emotional per-
sons, or actions which are conditioned by inner motives of which the
subject himself is not sufficiently conscious, and this is especially the
case in schizophrenics. Some sudden obsessive actions are also often
inaptly called impulsive, and of course also the raptus observed in
melancholies.
Certain pathological actions, like obsessive and automatic actions
are abnormally related to consciousness or to the will.
Obsessive actions are conscious actions running counter to one's
own will, and proceed from an inner impulse which the personality
cannot resist. In most cases the resistance is connected with fear
or some other vague uneasiness, to the influence of which the per-
sonality finally yields, in the same way as a physical pain forces a
person to do something which he does not wish to do.
Impulses tov/ards indifferent actions, to the extent of compulsive-
like exclamations of indecent or sacrilegious words (Coprolalia), occur
frequently in different states. In so far as they refer to serious crimes,
like murder of relatives, they are rarely irresistible outside of schizo-
phrenia. Indeed, one deals most frequently with apprehensions lest
one might do something, rather than with real impulses.^^ To be sure,
those apprehensions are nothing but effects of impulses repressed into
the unconscious.
Automatic Actions are not directly noticed by the patient himself:
he neither feels that he wishes to accomplish the action, nor that he
executes it. If the action lasts for some time, he takes notice of it
like a third person, by observing and listening. This occurs in schizo-
phrenia, where in this way windowpanes are frequently broken,
clothes torn, and beating administered, but automatic actions may also
be present in an especially clear formation, in forms of hysteria and
in artificial trance-states, where they may appear in complicated and
senseful actions. Here the mouth speaks, reproduces apparently the
thoughts of the spirit, preaches, and the hand writes. Most people
can apparently be quickly educated to automatic writing by skilful
suggestors I know of a quack who made all his patients automatically
;
write out their diagnosis and the remedies to be applied. Every

"medium" in spiritistic circles does automatic speaking, and in re-
ligious epidemics (preachers in the Cevennes and others) automatism
draws quite a large circle of followers. It is easy to understand that
such people acquire the idea that they are possessed of a spirit
(Demonism) If the latter expresses what they consciously think or
.
wish, then a good spirit, otherwise it is a bad one; it is not at all

it is
unusual to observe that the patients frequently have to do exactly just

what they do not want to do as, for instance, to utter ugly or sinful
words [Automatic Coprolalia).
A very good description of a schizophrenic patient is the following:
"Suddenly Dolinin (the writer himself) felt, that not only without
his wish, but even against his will, his tongue begins to express loudly
"Cf. obsessive ideas, and Compulsion Neurosis, p. 87.
and at the same time most rapidly that which in no case should
have been uttered. At the first moment the patient was perplexed
and frightened by the very fact of this unusual occurrence, because to
be suddenly and obviously aware of a wound up automaton in oneself
is per se disagreeable, but when he began to grasp the meaning of what
his tongue chattered, the horror of the patient increased, because it
showed that he, D., openly confesses his guilt to a serious political
crime, sometimes ascribing such plans to himself which he had never
entertained. Notwithstanding this fact, his will did not have the
power to restrain his tongue, which had suddenly become automatic}'^
Within the automatic actions there are different mechanisms. It
may happen that something is executed which the patient wishes to
do, but he does not feel the will impulse nor its accomplishment.
When he wants to eat, to give his hand, to walk, or when he merely
would be ready to do so, his limbs carry out the action, and yet he
has not the feeling that it has been accomplished at his instigation
(in schizophrenia). His limb can also carry out something, his mouth
can say something, which the patient might not wish. He feels the
impulse, wants to resist, but has no power; the innervation of his
muscles is directed by another will. From this there are all transi-
tions to the obsessive actions, and the other will is naturally not a
strange one, but a repression of the patient's own striving (in Hys-
terics, Schizophrenia). Not a few automatic actions remain also
unconscious in execution, for instance, when a hysterical woman
crushes rose leaves against her temple during conversation as a symbol
of the thought of her lover's death, who shot himself through his
temple. Such automatisms may also be the prototype of many schizo-
phrenic stereotypes.
Automatic actions which are formed by practice evidently have
quite different mechanisms. In walking, riding, cycling, piano play-
ing and indeed in all our occupations we carry out a number of simple
actions which we neither start consciously nor direct consciously. As
a rule, these are willed actions, but not always; somebody may do
something which he wôuld not carry out consciously, as to pick his
nose in company, to show a sign of disdain, and similar acts.
Similar to such actions are some of the apparent stereotypes of
organic patients which evidently pass off automatically in most cases,
but represent actions which already have been practised before the
disease, like the incessant twirling of the moustache, etc.
The list can still be completed by some types w^hich although
^ Kandinsky in Jaspers, AUgemeine Psychopathologie, p. 121. Julius Springer,
Berlin, 1913.
markedly differing from each other, however, have these in common:
sometimes they are carried out quite consciously, sometimes quite auto-
matically, sometimes they are done only in partial consciousness; and
sometimes they are only the expression of a mood. The twirling of
thumbs, scratching of the head in healthy people, and the swaying of
idiots represent some examples.
Just as in outer actions, thinking also may proceed compulsively
or automatically, without and against the will of the patient. If an
idea continually keeps on obtruding itself against the will, we deal with
an obsessive idea. But beside this form of obsessive thinking there is
another quite different form of- compulsive thinking, which only occurs
in schizophrenic patients, and rarely in epileptic equivalents where
the patients feel that "it" thinks in them often the same thoughts
that they themselves think spontaneously, but often the thoughts
are quite different; sometimes there is a confused crowding as in the
"thought crowding" of schizophrenic patients. Hence in such cases
the thought process as well as its contents are withdrawn from the will.
The theory of the automatic actions can easily be understood from
our conception of psychic processes. The associative connection
between the conscious ego-complex and the functions of acting is lack-
ing. The impulses to action are direct effects from the unconscious
acting upon the motor functions. The complexes from which they
logically originate can be demonstrated by the analyses of accessible
patients. Automatic actions of various kinds can be experimentally
produced in hypnosis.
Half automatic, though to a certain insufficient extent accessible to
the will, are the tics, which according to Oppenheim are movements
of a reflex, defensive, or expressive nature, which have deteriorated
into compulsive acts; these we have the displaying of the
among
teeth, clenching of and closing of eyelids. They are morbid
fists,
because they are repeated again and again without apparent motive.
The patient can resist the impulse for a short time, but not for very
long. Tics are naturally quite stereotyped.
for an action carried out sometimes consciously, and
The impulse
sometimes compulsively, can also come from without, as, for instance,
in automatic obedience, that is, the compulsive-like or also automatic
obedience to requests for simple actions of all kinds. The patients
carry out any commands whatsoever, even also if it is against their
will, as, for example, putting out their tongue when they know that
a pin will be stuck into it (Schizophrenia). The impulse for such an

action can also be given by means of example alone, as in echopraxia
and echolalia. Although this symptom is so closely related to auto-

GENERAL PSYCHOPATHOLOCJY 153
matic obedience that Kraepelin makes it a part of it, I have never

seen the two peculiarities run parallel in development. The echo-
practic patients imitate whatever strikes them in the actions or words
of their surroundings. As far as we know, it is partly a question of
hysteria-like mechanisms, as seen in the echopraxia of primitive peo-
ple,"^^ most cases of schizophrenia, and partly a matter
and certainly in
of an incapacity to get away from a conceived idea, so that instead
of giving an answer the question is repeated, or instead of a new action
the preceding act is imitated (organic echolalias and echopraxias).
In the latter case the patients usually wish to do or to say something
quite different, but the impulse turns into a wrong path. In hysteri-
form, or schizophrenic echopraxias, the person does not "wish" to do
something different; it is not a question of a derailment of an impulse
actually desired, but of an influence of the conscious or unconscious
wish itself.
According to Kraepelin, the phenomenon of fiexibilitas cerea (wax-
like flexibility), alsocommonly called catalepsy, also belongs to auto-
matic obedience. The patients make no movement of their own voli-
tion; but if they are placed in no matter how uncomfortable an attitude
they maintain it Thus, the patient can hold his
for a very long time.
limbs in an extended posture for a much
longer time than a normal
person could do voluntarily; usually they gradually sink without
trembling, and without any evident exertion on the part of the patient.
Some patients ofTer a certain resistance to the passive moving of their
limbs, which gives the impression as if a wax statue was modelled.
Most patients, however, move their limbs at a slight push, as they
guess what is wanted of them.
Much more frequently one finds in patients whose movements are
obviously quite normal, that if, for instance, an arm is somewhat
brusquely raised upwards, it remains so for a long time {Pseudo-
flexibilitas).
The schizophrenic and hysterical catalepsy can be psychically in-
fluenced to a high degree, which makes it probable that it is essentially
a psychic symptom; still there is a probability of its being based on a
peripheral tendency to tonic muscular disturbances. The other forms
are too little known.
Besides the flexible, there exists also a rigid catalepsy. Patients
evincing a stereotyped attitude must naturally keep the corresponding
muscles in constant tone, and every passive change of the same is
often energetically resisted, giving the appearance of a wooden statue.
In the Malays thp compulsory imitation of simple actions is described as

Latah, in Siberian tribes as Miryachit.
The apparent counterpart of automatic obedience is negativism,
which, however, frequently appears with symptoms of automatic obedi-
ence, Negativistic patients refuse to do exactly what is requested
or expected of them (Passive negativism), or they do the opposite
(Active negativism) , so that in pronounced cases it is possible to direct
them by requesting the opposite of what
wanted of them. Nega-
is
tivism is often, but not always connected with an irritated response

to all influences from without, and consequently with a tendency to
anger and violence. Not infrequently negativism expresses itself in the
fact that the patients make an effort to start an action, when a

counter-impulse, or only a mere blocking appears and hinders them
in its execution. It is also probable that quite different impulses
(cross-impulses) interfere. In this way, negativism can also express
itself against its own impulses (Inner-negativism).*
Centrifugal disturbances have especially many relations to schizo-
phrenia while they recede in other diseases, or only appear as a natural
consequence of other disturbances. The schizophrenic morbid pictures
in which they appear in the foreground are called catatonias, and
the symptoms, which associate here particularly often in various com-
binations, are called catatonic symptoms. But the latter partly in
other genesis, and partly in a somewhat different form, may also occur
now and then in other diseases. Catatonic symptoms are: stereotypes
(of action, of attitude, of space, and verbigeration) mannerisms, auto- ,
matic commands with waxlike and rigid catalepsy, echokinesis and

echolalia, mutism (see below) negativism, impulsive raptus, the cata-
,
tonic form of stupor, and the disturbances of the will in the stricter
sense.
In general the will is indirectly influenced by the disturbances of
perceptions and thinking, and more directly by disturbances of the
affects. In catatonia there are disturbances of the will in a different
sense. What we call will seems to merge independently into wrong
paths. The patients cannot do what the conscious part of their ego
would wish, they cannot will what they recognize as good; yet these
actions are not automatic, but conscious, and in a certain respect they
are also willed by a split off part of the will. The following disturb-
ances have here been particularly emphasized: Hyperkinesis and
akinesis, impulsive actions, automatisms, negativism, and obsessive
actions.
The ajfective manifestations inadequate to the feeling belong al-
most entirely to schizophrenia. What impresses us in the affective
conduct of the patient outside of schizophrenia is conditioned by the
'"
For further details about negativism Cf Schizophrenia.
.
abnormity of the affect itself; an exaggerated manifestation is based

on an exaggerated affect. In schizophrenia one cannot so easily judge
from without to within: behind a tragic pathos there may be a very
light or even no affect at all. At the same time the manifestations
easily strike a false note which is often sensed with true instinct by
naive persons, and by very small children. Very frequently one ob-
serves an unmotivated laughter, which sounds artificial, and from
which we can easily recognize that it is not the expression of a real
gaiety. It can also be easily distinguished from the convulsive laugh-
ter of hysterical patients. In lesions of the thalamic regions one finds
occasionally obsessive laughter or crying in consequence of any psychic
stimuli with, or particularly without, a corresponding affect.
The abnormities of the mental trend are naturally expressed in
the content of speech. It is noteworthy, however, that not only in
aphasic, but also in schizophrenic patients, the speech utterances may
be quite incomprehensible {confusion of speech, "word salad," schizo-
phasia), while the corresponding thoughts remain clear as shown by
the orderly behavior and work of the patients.
Formally, the vivid speech of the manic patient expresses his
euphoric excitement, the retarded and low speech of the melancholic
his depressive inhibitions, the babbling and stammering speech of the
idiot his sensory and motor awkwardness, the inarticulate, syllable
stumbling speech of the paretic, his disturbances of coordination, and
the hesitating, singing speech of the epileptic, the dullness of his affect
and mental stream. The different dysarthrias in apoplexy and other
organic disturbances of the brain do not directly belong to our field
of research, as they are only accidental complications of the psychoses.
A persistent not speaking is called mutism; it is variously deter-
mined by negativism, delusions, and by hallucinatory prohibitions to
speak, but mainly by the fact that schizophrenic patients have nothing
to communicate to their environment, and that they do not even take
notice of questions put to them.
The handwriting shows quite analogous disturbances. Orthographic
and grammatical mistakes, wrong corrections, and blots, give evidence
of the patient's psychic defects. Imbecilic awkwardness and paretic
disturbances of coordination impress on the handwriting a mark which
is easily recognizable; the same is true of the manic mobility and
excitability as well as of the melancholic inhibition. Some schizo-

phrenic handwritings contain kinds of strange letters and flourishes,
all
orthographic peculiarities, abnormal formations of lines mixed with

unintelligible signs, and similar peculiarities. The content of the writ-
ings gives us just as important enlightenment as regards the psychic
life of the patient as the spoken utterances; often it is even more im-
portant, because in writing the patients are by themselves and are
more free in expression. A skilfully dissimulating paranoiac used to
confide his delusions only on toilet paper; and as his wife, who
suffered severely in consequence of his disease, collected these docu-
ments she obtained the necessary material for divorce and guardianship.
CHAPTER m
PHYSICAL SYMPTOMS
Among the physical symptoms those of a neurological nature are

especially important, because on the one hand many psychoses are
partial manifestations of an organic affection of the central nervous
system, and on the other hand the functional neuroses are mental dis-
eases. Although it is a matter for the neurological clinic to deal with
the semeiology, we shall mention here some of the most important
symptoms for orientation.
Paralyses occur in the organic brain diseases, especially in idiocy,
paresis, and in Korsakoff's disease. In the latter case paralyses are,
of course, mostly peripheral. Psychic paralyses occur less frequently
and are of hysterical genesis, even if found than hysteria.
in cases other
Many paralyses result in contractures. There are aleo primary
(hysterical) contractures.
Real convulsions occur in epileptiform, paretic, catatonic, and hys-
terical attacks. Huntington's disease is always accompanied by
choreic movements. In ordinary chorea the psychic disturbances some-
times rise to the height of a psychosis. The slow athetoid movements
which ordinarily confine themselves to a limb or to half of the body
are manifestations of brain lesions in postencephalitic idiocies or
apoplectic dementia, and other similar cases. Other convulsive mani-
festations are chewing motions and grinding of teeth in idiots, in
organic patients, and in acute delirium. The European sleeping sick-
ness (Encephalitis lethargica) shows all sorts of hyperkinesias, par-
ticularly a stiffness of the muscles of mimicry which is not the same
as the schizophrenic "rigidity" but as it is often associated with in-
difference and lack of energy, it cannot in itself be differentiated from
schizophrenia.
Disturbances of coordination of a very definite form belong to
the picture of paralysis, while bad coordination of motion in general,
to the middle and higher grades of oligophrenias.
Tremors very frequently accompany the psychoses. Thus we have
the fine, even tremor in uncomplicated chronic alcoholism and in some
cases of schizophrenia, the various kinds of coarse tremors in all
organic diseases, such as the severe forms of alcoholism and delirium
157
.

tremens, the febrile toxaemias and some cases of exhaustion. A form
of organic tremor is especially seen in simple senile dementia and quite
regularly accompanies this disease. Irregular tremors are often only
a sign of some form of excitement.
With the exception of the Babinski, the cutaneous reflexes are
practically of no significance in psychiatry. More important are the
tendon or deep reflexes, the latter are increased wherever control
by the cerebrum is disturbed, as in idiocy, in hysteria, also in dementia
prsecox; this phenomenon is naturally most pronounced in the organic
psychoses. The crossing over of the patellar-reflex to the other leg
most frequently to the adductors (contra-lateral movement), if the
reflex can be elicited through the tibia or patella, indicates with rea-
sonable probability an organic disturbance. Through affections of
the peripheral nerve and the cord the exaggeration can be overcom-
pensated even to the total disappearance of the reflexes (Alcoholic
Korsakoff, tabo-paresis)
In the diagnosis of hysteria some people attach import,ance to the
absence of the pharyngeal-reflex. This reflex is also absent in bromism
and in many normal persons, depending entirely on the examination.
The disturbances of the pupilary-reflexes depend on the organic
affection. In paresis, one usually finds rigidity to light (Argyll-
Robertson's phenomenon), but it is also an important sign of other
syphilitic affection of the nervous system; it may also occur transi-
ently in organic forms of alcoholism and also in sleeping sickness.
Catatonia seems to favor functional pupilary disturbances which are
as yet incomprehensible.
Anesthesias and analgesias have already been mentioned, also
hyperesthesias (p. 55). Paresthesias can have an organic origin in
degenerations of the central or peripheral nervous system, or they
can be psychically determined. Slight degenerative and toxic proc-
esses seem to produce changes in the physical sensations in cases of
schizophrenia, which in turn give cause for hypochondriacal delusions
and interpretations in the form of physical hallucinations.
The remaining physical functions are effected in some cases by
the psychic alterations (loss of appetite in depression), in others they
are organically determined by the underlying disease, such as paresis,
and in still others they are the cause of the psychic alteration (Base-
dow psychoses, athyroidism, cases of amentia).The insomnias which
regularly accompany the acute have very divergent connections.
states
Menstruation often stays away for some time in acute psychoses;
at least the subjective sensations of menstruation such as pain, etc., are
very uncommon in chronic diseases where the patients no longer think
PHYSICAL SYMPTOMS 159
of the function this is particularly the case in schizophrenia. In cases

of debility where, on the contrary, such things are very important, one
finds many menstrual difficulties. Childbirth proceeds very smoothly
when the disease absorbs the patient to such an extent that the
physiological act is not disturbed by the psyche. This shows that
it is essentially the interference of the psyche which makes the func-
tion of childbirth so remarkably burdensome. Even women who at
former confinements needed artificial assistance are wont to go through
easy births in the psychoses, unless serious anatomical hindrances are
in the way. The potency with the libido is diminished in some de-
pressions, in morphinism, in many schizophrenics, in the excited initial
stages of organic psychoses, especially in paresis; but in senile cases
whose sexual impulse seems almost extinguished the potency and
libido are sometimes increased. In chronic alcoholism, only the libido
is enhanced while the potency is diminished in most cases.
At the height of the depression there is an absence of tears. In

schizophrenia all secretions may be disturbed quite capriciously in
the most varied ways. In cases of refusal of nourishment and nat-
urally also in diabetic psychoses, one often finds acetone in the urine.
Metabolism markedly influenced in a most incomprehensible man-
is
and dementia prsecox where one frequently

ner, especially in paresis
notes fluctuations from extreme marasmus to excessive obesity and
the reverse. In acute diseases the bodily weight usually diminishes,
and increases during convalescence.
For the rest one knows a lot of details about disturbances of diges-
tion, of metabolism, and of the blood picture, but as yet ver>' little
that is constant, that is sufficiently comprehensible, or that would
contribute to the understanding. The temperature is normal in almost
all psychoses, but one also observes febrile attacks, particularly in
paresis, where it is and in hysteria where it is
cerebrally conditioned,
psychogenetically induced. Subnormal temperatures are sometimes
encountered in marasmic conditions, in cerebral affections, and also
without any explanation in schizophrenia.
The heart and vasomotor system remain uninfluenced in no
psychoses, except perhaps in paranoia.
In paresis, perhaps also in senile processes, and in schizophrenia,
one sees tabetic and other rarefications of the bones. Other trophic
disturbances such as the tendency to otohaematoma and decubitus
are variously determined in organic diseases.
With the aberration of the cerebral predisposition which is at the
basis of many mental merges
diseases, the physical development, too,
into false paths, A great number of patients carry with them manj-
malformations, or surely more than the average of those mentally
normal, from a subnormal bodily height, deformed skull, badly formed
ears and palates, irregular position of the teeth or insufficiently de-
veloped teeth, to the abnormal length of the vermiform appendix.
For a long time great stress was laid on these "degenerative signs"; in
individual cases it is hardly permitted to draw any conclusion about
the psyche from either their presence or absence. On the other hand,
they predominate as a whole in oligophrenics, in epileptics, and crimi-
nals, and less in other mental diseases. They have apparently some-
thing to do with injuries of the germ and point to a teratologic origin
of the disease. The diseases which are sometimes described as "de-
generative psychoses," namely, paranoia and manic depressive insanity
are very frequently found in persons of particularly good physical
development.
CHAPTER IV
THE MANIFESTATIONS OF MENTAL DISEASES
A psychosis is generally a complicated structure which may mani-
fest itself in very different ways, not only from one patient to another,
but in the same patient at different times. The manifestations were
formerly taken for the diseases themselves/ and even yet it is of
practical value to emphasize them as pictures of morbid states and
as syndromes.
MORBID STATES
The manic state: On the affective side one observes an exalted
and very changeable mood which is especially easily transformed into
anger; in thought, there is flight of ideas, centrifugal pressure activity;
as accessory symptoms one not seldom sees overestimated and
grandiose ideas.
The expressions "mania" now usually means the manic state of
manic depressive insanity. In countries speaking the Romance lan-
guages or English it still designates generally any excitement especially
when it evinces itself in motor expression.
When the euphoric excitement gives a feeble and stupid impression,
some still speak of it as Moria. Distinct flight of ideas need not be
present, Moria occurs especially when manic attacks are subsiding,
and in lesions of the frontal lobe. To be sure, exalted moods in de-
menting psychoses of any kind frequently also manifest a similar
appearance.
Depression or Melancholic states with a painful accentuation of
all experiences, retardation of thought and of the centrifugal functions.
As accessory symptoms: depressive delusions.
The expression "Melancholia" designated for forma long time the
of melancholia of the "involutional period," especially
emphasized by
Kraepelin, and is now also used to designate the depression of manic
depressive insanity by those who have fused the two morbid pictures
into one.
^ Kahlbaum
deserves the credit for having made a deliberate and sharp dif-
ferentiation between "conditions" and '"diseases," even though in his time the
position of science had not yet made it possible to circumscribe natural morbid
pictures more exactly.
161
The manic and the melancholic (depressive) states we see almost
in pure form in the commonmanic depressive insanity, also
cases of
accidentally more or less frequently in most other mental diseases.
Delusional insanity refers to acute conditions in which delusions
and hallucinations or even only one of the two symptoms dominate
the picture to such an extent that the patient loses his pose, and
frequently also his orientation.
The expression is now rarely applied to chronic conditions. When
a distinct emotional fluctuation combined with it, or, what is usually
is
the same thing, when one deals with an onset of manic depressive
insanity, one also speaks of manic or melancholic insanity.
What for a time was called delusional insanity ("Wahnsinn") were
mostly hallucinatory excitements of schizophrenia. We still use the
name only for the forms of manic depressive onsets, which cannot be
otherwise classified, in which hallucinations and illusions more or less
conceal the fundamental complex; we use it at times for similar schizo-
phrenic pictures.
Meynert once believed that under this name ("Wahnsinn") he
described a particular disease. He later substituted for it the term
amentia.
The term Confusion is ambiguous; in the first place it designates
the thought disturbances described above ^ that have no limits as to
incoherence and dissociation. But more complicated conditions of
very different origin are also designated in this way, being conceived
at times as syndromes, at times as pictures of conditions and at times
as diseases. According to Ziehen, confusion is a symptom complex,
consisting of disorientation, incoherence of the course of ideation and
motor incoherence. The ''diseases" designated as confusion corre-
sponded approximately to the newer amentia of average degree.
Here we use the expression only for the above named mental
disturbances.
"Hallucinatory Confusion" symptomologically about the same
is
as the broader amentia ; what is still so called belongs nearly

therefore,
altogether, in part to our amentia, and in part to schizophrenia.
Only conditions that last for a long time and that are conceived as
an entire disease are called amentia. Like confusion, it cannot be
sharply defined symptomatically from twilight states and the deliria,^
concepts, that we cannot as yet dispense with entirely. Transient con-
fusion, twilight states and deliria, be they pronounced or merely indi-
cated, we called "clouded states."
'Cf. p. 86.
='Cf. p. HI.
THE MANIFESTATIONS OF MENTAL DISEASES 1G3
Acute delirium is now a rare brain disease. It is evidently based

on different infections or on schizoplirenio processes, and shows itself
in deliria, convulsive manifestations, and in most cases in a rapidly
ending death.
Hallucinosis is Wernicke's designation for acute hallucinatory con-
ditions in which, in contrast with the deliria and the greater part of
the twilight states, orientation and, in part, clearness, are retained
(alcoholic hallucinosis).
Dreamy state is nothing but another name for twilight state.
Transitory psychoses * are attacks which appear and disappear
suddenly, with disturbances of consciousness of brief duration. They
occur in the manifold psychopathic states (Magnan's boufTees
delirantes) with or without affective or toxic cause, then too, in latent
and manifest forms of real psychoses, especially in schizophrenia and
epilepsy. Many may be included in the concepts of twilight states.
At times they are the cause of crimes.
Stupor '^
is a state of various origins that occurs especially in
schizophrenia, then in hysteria, epilepsy and also in auto-intoxication,
etc., rarely in manic depressive insanity. Emotional stupor is a syn-
drome seen in different conditions, especially in the different kinds of
"nervosities," in the widest sense, and in the oligophrenias.
Stuporous forms with almost complete immotility are designated as
Attonity. This is usually a catatonic condition; but a melancholia
attonita has also been distinguished; whether the latter exists, i.e.,
whether the retardation of merely depressive conditions may rise to a
continuous immotility, is questionable.
Under cloudiness we understand different conditions of narrowed,
unclear, slowly performed thinking, in which stimuli are lacking or
at any rate merge into the background. Such conditions are seen in
slumber, in fever, in epilepsy, in schizophrenia, and in organic states
of all kinds. A part of these pictures naturally may just as well be
called stupor.
The picture of the condition of hypochondria consists in continuous
attention to one's own state of health with the tendency to ascribe a
disease to oneself from insignificant signs or also without such. It
occurs in dementia praecox, in depressive and neurasthenic conditions,
in initial stages of organic psychoses (arteriosclerosis, paresis), and
in psychopathic states of all kinds. AVe no longer recognize hypo-
chondria as a disease.
Catatonia as such is a manifestation of schizophrenia. But cata-
* Formerly in their excited forms also called transitory manias.
"Cf. pp. 143-144.
tonic symptoms also occur in organic mental diseases, in epilepsy and
in fever psychoses.
Paranoid symptoms is the designation for hallucinations and de-
lusions when they appear in a state of mental clearness and without
(primary) fluctuations of the affects.
"Acute (hallucinatory) Paranoia" was conceived by Ziehen and
others as a disease. The majority of these so called conditions belongs,
in our opinion, to the acute manifestations of schizophrenia.
Religious mania, or mania religiosa, is any mental disease with
religious delusions; it is thus mainly a question of dementia prsecox.
Nevertheless some observers still designate a melancholia with pro-
nounced delusions of sin as religious mania.
Dementia (feeble mindedness) is not a uniform condition. One
deals here with a purely practical conception. Whoever fails in life
because of intellectual insufficiency is demented. In a scientific sense

there no uniform dementia, but only an oligophrenic, epileptic,
is
organic dementia, i.e., forms which in their entire character are very
different from one another. The diagnosis "dementia" is scientifically
never sufiicient; one can diagnose only a particular kind of dementia.
As psychopathies we designate the mass of congenital or at any
rate permanent psj^chic deviations from the normal which have not
yet been included into any other class, and which exist chiefly in the
borderline between health and disease. Among these one naturally
finds many undeveloped real mental diseases, especially latent schizo-
phrenia. Many believe that they connect a well defined conception
with this expression, but they are certainly mistaken.
Degeneration.^ "Degenerates" are usually about the same type as
psychopathies, namely, individuals who intellectually and especially
affectively react differently from the average. "Degeneres superieurs"
(superior degenerates) are psychopaths who stand above the average
in some line and can maintain themselves in the world. It is only
just to state that famous men belong to this class.''
SYNDROMES
Syndromes are complexes of symptoms that belong together
genetically. A part of such pictures as manic depressive insanity,
eventually with their corresponding delusions, represent at the same
time such syndromes. One speaks, furthermore, of an "organic symp-
tom complex," also called the Korsakoff syndrome and understands by
'Cf. p. 201.
'
For some etiological designations see end of the chapter on Causation.
THE MANIFESTATIONS OF MENTAL DISEASES 165
this term the sum of the psychical fundamental symptoms of a diffuse

atrophy of the cortex, or of a general lowering of the function of
the cortex through shock or injury of the brain.*
The Katathymic delusional formation, i.e., a delusional formation
with clearness in other respects, which is not due to a general moodi-
ness but to a definite "complex," or a particular experience, is a syn-
drome in itself. combined with hallucinations forms the
It alone or
paranoid syndrome, which is to be distinguished from the paranoid
constitution. The latter type of personality readily refers the actions
of others to himself, or interprets them in the sense of a definite atti-
tude (suspicion, persecution, grandeur) without progressing to the dis-
tinct formation of a real delusion. We can also mention here the
hysterical and neurasthenic symptom complex,'^ the compulsive symp-
toms, the anxiety psychosis and anxiety neurosis, also the fright neu-
rosis, the expectation neurosis and the twilight states, because they
are all produced by mechanisms on different foundations such
definite
as the psychopathic, hysteric, and epileptic. Under the twilight states
several types are to be distinguished, which permit of fairly good
differentiation on the basis of their psychic genesis: thus we have the
Ganser Syndrome, which represents a "mental disease," in the form
of acting and thinking in a manner which is the reverse of the normal;
the buffoonery syndrome in which the patient plays the fool in the
"vulgar" sense; ^^ puerilism," when the patient behaves like a little
child and the pseudo-dementia in which the patient "knows nothing."

Moreover, wishes are not only realized through the twilight states but
also hallucinatorily in the twilight states, inasmuch as the patients
dream themselves into the desired situation. The wish to be insane
and to appear irresponsible is fulfilled through the Ganser state which
is a mental disease, or the wish to be innocent and pardoned is realized
in the prison delirium which dehides the patients with the fact that
they are innocent or forgiven. The maximum of wish fulfilment is
achieved by the ecstasies.^- These syndromes are also called Purpose

psychoses.
Among the twilight states the wandering mania (poriomania,
fugues) deserves special consideration. It manifests itself in a run-
ning away that completely aimless, or dominated by a single con-
is
fused and uncontrollable idea; at times it is merely motor without
''Cf. p. 230.
* For the kinds of manifestations
see the corresponding diseases.
^"As in spoiled children, the buffoonery observed in schizophrenia may excep-
tionally be used as a means to hide the despair.
" Not to be confused with infantilism.
"Cf. p. 113.
any consideration for the outer world except what is necessary for
running; at times it is externally inconspicuous, the act seems planned
with correct use of transportation and with the possibility of contact
with other people; at other times it is done in a way that it can be
placed between these two extremes. The milder forms are rather
psychogenic and may therefore occur everywhere, even in hysterics and
ordinary psychopaths, especially in those who are young, as a result
of an exciting experience, a temptation, or an unbearable situation.
The severer forms belong chiefly to epilepsy, while those who are mid-
way between the two classes belong in the main to schizophrenia.
Querulousness is generated by an exalted self-consciousness where
there is activity and lack of understanding for the rights of others ; this
occurs in schizophrenia, paranoia, manic depressions of long duration,
traumatic neurosis, and prison confinements. Aside from the affective
explosions of rage (prison outburst), confinement produces conditions
in which on the one hand the patient imagines himself pardoned,
acquitted, or innocent, on the other hand persecuted by those about
him. Syndromes that are put in motion by a definite situation, as
prison psychoses, Ganser, etc., transitory affect psychoses, and even-
tually also querulousness, are also comprehended under the name of
situation psychoses.
Further syndromes are "attacks," such as the epileptiform in the
narrower sense with petit mal, Jacksonian epilepsy, paretic, and cata-
tonic attacks.
Hoche wanted to supplant the pictures of diseases that are still
too fluctuating by the theory of the syndrome, urging that one should
be satisfied with a diagnosis of the latter. But even the syndrome
theory is by no means complete; the identical syndrome has an en-
tirely different significance for therapy and especially for practice,
according to whether it occurs in an hysteria, or epilepsy, or schizo-
phrenia; besides we now know altogether too much about the "dis-
eases" in the ordinary sense to be able to disregard these conceptions
without a severe loss to science. On the other hand, it would be an
advantage to carry out a syndromistic treatment of those symptom
complexes that are only deviations from the normal average either in
predisposition, as in psychopathic conditions, or in reaction as in neu-
roses, purpose and situation psychoses, and paranoias.
CHAPTER V
THE COURSE OF MENTAL DISEASES
Few generalizations can be made concerning the course of mental
diseases. The congenital mental diseases run a "course" only to tlie
extent that at times they show acute syndromes or sometimes progress

as in puberty, or that they combine with a new disease such as epilepsy,
schizophrenia, alcoholism, or atrophy of the brain.
In acquired psychoses one frequently speaks of prodromal stages,
but here as in most cases they represent nothing but such mild morbid
symptoms, that a diagnosis is impossible. The most frequent of these
are: depression, exaltation, eccentricities, nervous symptoms or
changes of character, in which the new attitude may resemble the
character of many healthy people, and in itself, therefore, does not
necessarily seem morbid. To be sure, all the real signs of mental dis-
eases in a less marked form may also have the significance of
prodromes.
The "beginning of the actual disease" is usually furtive if one does
not designate acute episodes in chronic pictures as "the" disease, as
frequently used to happen and even now occurs in the onsets of manic
depressive insanity. At all events certain deliria, hysterical twilight
states, and similar processes are in the real sense acute.
The entire coursemostly chronic, even in the sense of psychiatry,
is
which also designates as acute diseases depressions extending over a

period of years, provided they regain normal balance. Here the term
"acute" has come to mean approximately something transitory- while
the term "chronic" something incurable. In organic psychoses, which
after a long while end in death, one usually avoids the division of
acute and chronic, as far as the disease is concerned.
During the course one encounters acute shifts, acute onsets, exacer-
bations and remissions. Shifts are rapidly appearing aggravations of
the disease; the concept usually indicates that the given aggravation
does not usually equalize itself. Shifts are often connected with some
form of excitement and other accessory symptoms, which except for
the given lasting injury may recede to former states. Paresis and
schizophrenia are usually first recognized as diseases during such
167
"shifts" after they have furtively transformed the patient for some
time. many of these shifts assume the form of
In dementia praecox
schizophrenic manias and melancholias, of catatonias, and other syn-
dromes that were formerly considered special psychoses. Exacerba-
tions are aggravations in general, especially such as readjust them-
selves. Among them one observes many psychically determined
excitements, or twilight states (e.g. in schizophrenia), that are not
directly connected with the process of the disease, but are only transient
reactions of the diseased psyche to certain stimuli. To be sure they
generally disappear, leaving no trace of themselves. The term, exacer-
bation, does not usually designate the acute attacks that belong to
the morbid picture, such as the moodiness and twilight states of
epilepsy or the manias and melancholias of manic depressive insanity.
All the mentioned transient states of chronic diseases, taken together,
may be designated as acute onsets. Between the aggravations there
are remissions ; whether one may assume intermissions in forms
also
like manic depressive insanity depends on the conception. With
Kraepelin, Magnan and others, we designate the whole permanent
state of manic depressive insanity as the disease, and the acute appear-
ances may also alternate with one another in regular sequence so that
mania follows melancholia and the latter follows mania, etc., eventually
with normal intervals after the mania or after the melancholia or
after both. Such formations are called circular or cyclic forms. Out-
side of manic depressive insanity they occur occasionally in schizo-
phrenia and also in paresis.
How many insane patients are cured depends in institutional statis-
tics very much on the quality of the cases received into the hospital,
otherwise primarily on the physician's conception of cure. Whether
a schizophrenic patient who is perfectly competent socially, and in
whom some remnants of the disease can only be demonstrated after
a minute examination, may be considered as cured or not, is a matter
of taste. I would rather not call him cured, in view of new aggrava-
tions that usually appear later, such as the question of marriage, and
similar consequences, although I am aware that the disease may also
"definitively remain quiescent." Delirium tremens, which in hospital
statistics often shows a large percentage of cures, is, to be sure, as a
rule totally gone at the discharge, but not the alcoholism that lies at
its basis, i.e., the disease is cured but the patient is not. In residual
schizophrenic states "cures" sometimes take place even many years
after the patient has long been given up; this occurs in some without
any visible reason, in some as a result of a febrile disease, or a change
of environments, and similar things.
THE COURSE OF MENTAL DISEASES 169
Cure with a defect is also spoken of by formulating the concep-

tion, suitable only to few cases, that the acute disease has left a defect
just as a healed wound leaves a scar. A "psychic scar" may be formed
by definite "residual symptoms," as in the case of a delusion which
in spite of returned clearness following a delirium is no longer cor-
rected. If the psychic scar is so severe and multiform that it may be
considered as a disease in itself, the morbid picture was formerly desig-
nated as secondary to distinguish it from the primary disease that
formed it ("secondary dementia," "secondary paranoia"). The con-
ception must now be given up as in such cases it is nearly always a
question of dementia pra>cox, which does not change its nature.
Nearly all organic mental diseases and some severe cases of other
forms, e.g., of catatonia end in death. Of the remaining a small part
indirectly ends fatally through suicide, unhygienic living, refusal of
nourishment, exhaustion from restlessness and insomnia, injuries, and
infection.
In making the prognosis we have to differentiate the "direction
prognosis" and in chronic diseases, in addition, the "extent prog-
nosis." Organic mental diseases run in the direction of a definite
dementia and end in death; the epileptic and schizophrenic follow the
direction of other kinds of dementia and usually do not end in death.
Within the realm of schizophrenia there are again different directions
such as the paranoid, catatonic dementia, etc., that have to be con-
sidered in the prognosis. Not less important is often the "extent
prognosis," i.e., the prediction how far the disease will progress within
a conceivable period. Will the disease soon come to a stop, or will
there be some improvement? Will the patient become socially in-
competent through dementia? Or will he be able to maintain himself
in spite of the disease? And under what circumstances? In dementia
praecox, epilepsy and the severe forms of manic depressive insanity
these questions must often be put and sometimes their answer is pos-
sible with considerable probability.
CHAPTER VI
THE BORDERLINES OF INSANITY
Nowhere is the question: "sick or not sick?" put so often, in such |
an inexorable manner and with such heavy consequences as in the

judgment of mental conditions. But the given question is false. There
are no borderlines of insanity, no more than for any other disease.
In every person a tubercular bacillus occasionally takes hold; one or
the other of the microbesmay even divide once or twice. How many
bacteria must be present, how much living tissue must have been de-
stroyed before the individual should be called tubercular? Or begin-
ning with what degree of susceptibility is the ''predisposition to
tuberculosis" morbid? No one will want to answer such a question.
Still more senseless is the question about well and sick where it is not
a case of something added but of a plain deviation from the normal.
Where is the borderline between healthy stupidity and morbid feeble-
mindedness? Where the boundary between normal and supernormal
is
size of body? boundary line is lacking here, then there are

If the
extensive fields in which the conceptions "sick" and "healthy" are not
at all applicable, as little as the various shades of light in a photograph
can be divided into black and white; most of them are gray as a
matter of fact.
That the people and jurisprudence repeatedly demand an answer
to such senseless questions from the psychiatrist is due to the conse-
quences. They do not want to know whether a person is

really
healthy or sick, but they want to know whether he is to be taken
seriously, whether he is to be committed to a hospital, whether he
is responsible and capable of acting, etc., and all that they want to
infer from the confirmation "sick or not sick?" This method of infer-
ence is in itself wrong, not only because in a very wide zone the con-
ceptions sane and insane cannot be applied at all, but also because
there are patients that need not be committed, that may have good
ideas, that are not incapacitated, that are not irresponsible. Today
Schizophrenia and paresis may frequently be diagnosed before one
would care to act upon the social consequences of such a confirmation,
and with the refinement of our diagnostic resources such cases will
always increase. On the other hand, under certain circumstances a
170
THE BORDERLINES OF INSANITY 171
psychopath, who is may for a definite period have lost his

not insane,
an extent, that he is neither responsible nor
ability to reflect, to such
capable of action. And one will often have to decide within the
border zone according to external circumstances, since the same degree
of feeblemindedness, that does not harm the day laborer, at all, in-
capacitates the man who has inherited a large business.
The whole difficulty lies in the fact that there is no definition of
"disease" and there cannot be any. The fruitless controversies can
only cease when the ambiguous and indefinite concept is entirely ex-
cluded. enough to examine how a person is and reacts, and
It is easy
draw conclusions from the facts, instead of from a concept, and then
determine our actions accordingly.
Where chapters of the code contain_more_deiaild_jde.ciiptions of
the concept_jif_-disease, ' theyVary greatly according to the conte?
as the concept of insanity has become at all practical, it rests
not on medical or psychopathological criteria, but on the idea of social
inca;mcity. That is why, from practical points of view, the neuroses
whichRrfTprrT rly p y r Jxic dis t^nses, arp nn t^jnohiHpd inJ-nnnnity^ wVifrr
ii
they do not lead to severe syndromes like clouded states. All the more
they belong to theoretical psychiatry because they are comprehensible
only psychopathologically and have to be accurately known to differ-
entiate them from the other mental diseases. But much more severe
mental disturbances, as those in coarse brain diseases and in infections,
are usually not classed with the psychoses. From a medical point of
view the basic disease is taken as the only thing important; socially,
these disturbances have no significance especially because of their
brief duration, unless an important legal transaction happens at this
time.
Hence we shall use the expressions sane and insane only in very
pronounced cases and otherwise, in so far as we are compelled to. At
the same time, in the aberrations like mental debility, or psychopathy,
we shall take the capacity required under the given conditioiis as a.
criterion to determine the boundary of disease. But as soon as an
acquired disease is definitely proven, even though by few and rela-
tively mild symptoms, we shall speak of "disease in the medical sense''
and shall then have to put the questions, whether any conclusions and
which ones are to be drawn from this finding after a consideration of
all the circumstances.
A question which touches many people deeply is this, "Whether
genius is a disease or not?" Lombroso asserted that it was a disease,
while others have indignantly rejected this view. Now we do
here, too,
not know all we should like to know. But matters stand about like
this: 1. Genius is an aberration like any other; that it is much less
common than undesirable deviations is self-evident, because few defects

in disposition can make a man useless. One only becomes a genius
when a large number of attributes are simultaneously very highly de-
veloped. Genius may therefore run just as little true to strain as a
particularly fine variety of peach which as a single aberration was
accidentally cultivated by the gardener. 2. The tendency to aberration
usually involves the entire organism. Every domestic animal and every
plant, which can be cultivated along a definite characteristic, deviates
more readily in another direction. Those who are psychically abnor-
mal have (in the average) many physical "stigmata of degeneration"
and those who are physically abnormal have (in the average) many
psychic defects. In the aberration of genius we therefore, as a rule, also
find relatively frequently other abnormal which we must
qualities,
usually give a negative value (sensitiveness, nervousness, etc.). 3. Be-
sides, there is a connection between genius and mental abnormality:

The normal philistine is adjusted to the conditions in which he was
born, and balances with their little changes without thinking or noticing
much in the process. The psychopathic individual cannot adapt him-
self so well, or not at all; he reacts to difficulties resulting therefrom
either he may take refuge from the demands, in hysteria
by evasion,
or neurasthenia, or he may create an imaginary world himself for
through grandiose and persecutory delusion, or aggressively by at-
tempts to adapt the external world to his necessities, or by both to-
gether. Whoever would like the outer world different in large or
small matters is compelled to ponder over it and strive for inventions,
social betterments, etc. If he is also sufficiently intelligent, the facility
of avoiding the usual paths may be directly conducive to finding some-
thing new. Often the lack of adaptability lies rather in inner diffi-
culties, because the different tendencies do not equalize themselves
but lead to a lasting inner schism. Such people may combine the
contrasts in dereistic thinking or obtain satisfaction from without;
if they have the other necessary qualifications, they become poets or
artists. It is, therefore, not chance that famous men are so frequently
the offspring of unlike parents, whose tendencies do not fuse into a
unified whole in the psyche of their descendants, but throughout their
lives strive in different directions. Poets and musicians must also be
more sensitive than other people, a quality which is a hindrance to
the daily tasks of life and often attains the significance of a disease.
CHAPTER Vn
CLASSIFICATION OF MENTAL DISEASES
One class of the psychoses shows itself as a morbid reaction to an
affective experience, as a prison psychosis to a confinement, and an
hysterical twilight state to a jilting on the part of the beloved {reactive
psychoses, situation psychoses) . In the other class there is a morbid
process in the brain, that conditions the psychosis (process pychosis,
progressive psychosis) }But no division can be based on these classes
because the two symptomologies intermingle.
The terms "organic" - and "psychogenic" indicate similar differ-
ences. With the organic one naturally also classed the toxic psychoses
resulting from changes of metabolism, hormones, and from infections
and poisoning in the narrower sense. The idea of the Psychogenic is
not clear to many. It is said that psychogenic manifestations, too,
must "naturally" have an anatomical substratum; indeed, an anatom-
ical change has even been postulated for things like hysterical paralysis
of the arm. That is wrong. An hysterical paralysis as such has only
substrata, which in themselves are not pathologic; but as the founda-
tion of the hysterical disposition thereis a nervous system anatomically
chemically somehow differently
formed from that of the normal dis-

position. In a house there are doors and windows so that at times
they may be opened, at other times closed. If they are open or
closed, it is in itself no derangement of the structure; but if they close
or open too slowly or too easily, or if there is a rogue who brings it
about that they move too slowly or too easily, or who breaks them
or opens them when they should be closed, and closes them when they
should be opened, those are changes that may be compared with the
anatomical.
Endogenous and exogenous psychoses cannot be sharply differ-
entiated, not only because thetwo factors mingle or combine in their
effects but because the two concepts in themselves have no definite
^
For imd Psychose bei der Dementia PrEecox,
details see Jaspers, Schicksal
Ztschr. f. d. ges.Psych. Orig. XIV. S. 158.
Neur. u.
*The word "organic" designates here a much broader conception than in the

expression "organic psychoses" which in order not to have to coin a new

name I use for those psychoses that are based on a diflferent reduction of
brain elements.
173
limits. Idiocy, whether stationary or progressive, may be endogenous
in relation to the patient but may be the result of an exogenous influ-
ence on a parent. If schizophrenias are based on autointoxications,
they are exogenous in relation to the brain but endogenous in relation
to the body. Nevertheless Bonhoeffer's investigations of the exoge-
nous reaction types in toxic states and infections have been very
enlightening.
The attempt has also been made to classify on the basis of causes;
for example, alcoholic, infections, and traumatic psychoses have been
differentiated. But this principle cannot be carried out because some
causes produce very different morbid pictures, as syphilitic paranoid
states and paresis, alcoholic insanity and alcoholic Korsakoff's dis-
ease. And conversely, the same morbid pictures might be produced
by different causes, thus Korsakoff's diseases may be due to alcohol or
carbonic oxide gas. That the idea of causality is not clearly limited
need not nowadays be explained in detail.
Under Kraepelin's guidance the course of diseases has been particu-
larly emphasized, thus the same terminal state was supposed to be
proof that two different groups (not diseases) were formed which are
entities even in other respects, and will probably remain so for us.
We refer to dementia prsecox and manic depressive insanity. It is
nevertheless impossible to base a classification of morbid pictures only
on the course of the disease.
According to a more recent theory of these two groups of psychoses
one observes even in normal people a syntonic ("cyclothymic") reac-
tion type, in which the whole personality uniformly participates in a
definite and relatively vivid affect, suitable for the situation of the
moment, and the train of ideas follows substantially quite logical laws,
in that the affects disturb it only by connecting and overvaluing what
conforms to it, and by inhibiting and undervaluing what opposes it.
If at the same time the physiologically conditioned mood remains uni-
form throughout life and maintains an average pace, the representa-
tives of this type then pass as the most normal people. If it perma-
nently deviates to euphoric or depressive paths, its carriers are then in
a chronic mood; if the mood fluctuates (alwaj's for physiologic rea-
sons), those so afflicted are cyclothymic, or in the pronounced cases,
manic depressive. Studies of heredity show us, that the peculiarities
mentioned, somewhere belong together, that they represent a uniform
super quality, the "syntone," in which, although the individual sub
groups follow by preference a similar heredity, they can nevertheless
substitute one another in almost every family. Manic-depressive in-
sanity, Cyclothymia, chronic depressive and manic moods, appear as
CLASSIFICATION OF MENTAL DISEASES 175
exaggerations or other deviations of "normal" syntonic reaction

types.
Whereas the relationship of even the uniform (most normal) sy.^-
tones to the morbid fluctuations was first demonstrated by Kretsr-hrner,
the "schizoid" peculiarities of healthy persons was long known. Thus
there is a lack of uniformity of the affectivity, actual coexistence of
and a slight deviation of the asso-
different, nay, contrasting strivings,
ciations from the usual paths. Here too one must differentiate the
various qualitative or quantitative sub groups, which are frequently
inherited as such, but still change frequently within the main type.
Among those one finds persons who are dereistic, who show an affective
poverty, who are irritable, eccentric, paranoid, schizophrenic, schizoid,
etc. Now, even if the schizoid reaction appears mostly abnormal
following the canon which we have made for ourselves about psychic
normality, that too has as much biologic significance as the syntones:
Psychic new creations, inventions, political and religious revolutions
almost always owe their existence to it. Exaggerations or caricatures
of this reaction type come into existence as schizophrenic manifesta-
tions. But whereas according to our present, still very limited knowl-
edge, the manic depressive attacks are designated as "functional,"
at least the more serious schizophrenias are connected with tangible
cerebral changes; hence the most marked deviation from the normal
seems to be here in the first place not merely a strong fluctuation but
something new, still even in this relation it is nevertheless possible
to form a parallel syntone, at least hypothetic ally, between manic-
depressive and schizoid-schizophrenia.
Every man then has one syntonic and one schizoid component, and
through closer observation one can determine its force and direction
and can also put it in relation to his heredity, if the members of the
family are known.
Either both or only one of the reactions may be morbidly exag-
gerated in the same individual. The extreme cases then belong to the
pure manic-depressive and the pure schizophrenic diseases. Fre-
quently, however, we find distinct mixtures; preponderating manic-
depressive types with schizophrenic accessory symptoms and the re-
verse. These mixtures have been known to psychiatrists for a long
time, but they have been guided by it only in the prognosis and treat-
ment of the disease but not in naming it. Except in the rare extreme
cases we now no longer have to ask, is it manic-depressive or schizo-
phrenia? but to what extent manic-depressive and to what extent
schizophrenia? Confronted with such mixed forms we can say that
if the schizophrenic components, though distinct, do not definitely
follow the paths of dementia, the prognosis is still good, at least as
regards the present attack, otherwise it is bad; for the manic depressive
part of the disease is almost always transitory.
For not only would the schizophrenic-like symptoms in all manic

depressive forms owe their existence to schizophrenic components, but
conversely most of the melancholic and manic states in schizophrenics
would probably be an expression of the manic depressive components;
they would really have no direct connection with the schizophrenic
process. In many cases the latter connection could always be made
with the greatest probability by studying the heredity.
The theory has also some bearing on other diseases, namely, organic
psychoses. Poisons coming from without (alcohol, infections), as
from within (uraemia), will set free more schizoid symptoms, if the
schizoid factors of the individual are stronger, and more manic de-
pressive symptoms, the more syntonically the patient is predisposed.
This would thus furnish us with the explanation not only for the mixed
forms of manic-depressive and schizophrenic symptoms, but also for
the admixture of manic depressive or schizophrenic symptoms in quite
different diseases. As far as our experience goes this theory can be
fully applied to senile dementia. The preponderance of euphoric or
even manic symptoms in general paresis requires a special explanation:
Does the disposition to manic behavior also contain a disposition to
the localization of the spirochites in the brain? Or what seems more
probable, does the paralytic process or toxin produce a tendency to
euphoric reaction?
That under these circumstances the paraphrenias must all be added
to the schizophrenias is self-evident. One thinks less of the fact that
also the essential factor in all neuroses rests on schizophrenic mecha-
nisms ; one may think of the splitting off, the pinching off, the arraign-
ment of one impulse by the other, the inability to adjust to certain
situations (or better the will not to adjust oneself) , etc. To be sure
the syntonic components play some part in the formation of even these
morbid pictures. Thus to produce a hysteria in the ordinary sense
there must be a tendency to a labile affectivity in order to accentuate
one's own personality; a more depressive affectivity in the same
schizophrenic mechanism would lead to "neurasthenic" pictures. If
the affects are very constant and maintain themselves in a more central
position, a paranoia will develop in a schizoid mental type as a re-
action to inner and outer difficulties (Studies in heredity seem at last
able to furnish the long expected proof of the relationship between
forms of paranoia and schizophrenias) A simple uncontrollable affec-
.
tivity which leads to all sorts of primitive reactions, such as crying,

^
f CLASSIFICATION OF MENTAL DISEASES 177
window breaking, scratching up the husband, extravagance in love and

veneration, has its origin in the syntonic components.
The fragmentary theory here presented is for the present only an
hypothesis; but could be demonstrated with remarkable elegance in a
large amount of material of healthy and sick people; its correctness
at least as far as its general features are concerned can therefore
hardly be doubted. It is even more important when we find that the
two psychic types also show a certain predilection for definite physical
constitutions; to be sure these connections are more complicated and
less definite than those based on psychic spheres; but Kretschmer's
Pyknical physical type, e.g., must somewhere show a particular rela-
tion to the stronger syntonic reaction types.
In recent years anatomical investigations have carried us forward
very nicely, in that, for instance, a clearly circumscribed picture could
be distinguished of dementia paralytica, of various forms of senility,
and of several diseases that may be designated clinically as epileptic.
As in somatic pathology we are not accustomed in psychiatry to
apply concurrently different principles of classification, and through
the services of Kraepelin we have attained in barely two decades a
point of view, which compared with the earlier one, is entirely satis-
factory. Even though, as everywhere else, there is much we should
know in order to see clearly, and though there are surely still many
diseases that we do not know, nevertheless compared with the com-
plete helplessness of previous years we have achieved a point of view
from which it is possible to gain new ground steadily.
Therefore I follow, as far as possible, Kraepelin's classifioation,
which is now pretty well understood in the whole world, even if it is
not everywhere accepted, while all other schematizations are viable
only in certain schools.
Combinations of psychoses are still insufiicintly studied. A schizo-
phrenic or a manic depressive patient may be taken with fever-
delirium, delirium tremens, paresis, or dementia senilis; alcoholism
is not at all rare, especially in women where it is a symptom of
schizophrenia. In such cases the symptoms of the two psychoses
combine and under certain circumstances as in the interconnected
hallucinations of the schizophrenic delirium tremens, thej' fuse into a
unified and peculiar nuance. Sometimes one disease apparently forms
the essential picture ;no pronounced second disease but a mere
there is
predisposition colors the symptoms.
^ For more information see Kretschmer Korperbau und Charakter. Springer,
Berlin 1921, and Bleuler: Die Probleme der Schizoidie und der Syntonie, Zeitechr.
f. d. gesam. Neurol, u. Psychiat. 1922.
Recently an attempt was made to place the classification of the
psychoses on an entirely different basis by emphasizing the various
factors participating in the causation, development, and course. I
made the effort to initiate these viewpoints also here but had to desist
from it.*
Even if only the most important combinations would have been

presented it would have been so complicated that not alone the be-
ginner would have had much trouble in understanding them. On the
other hand if one is well acquainted with the present grouping of the
symptoms, it is no longer a clever feat to recognize and sufficiently
differentiate in the same patients such conditions as congenital de-

bility, alcoholism, manic states, and perhaps even the beginning of
senile dementia. If the new demands would be followed many repeti-
tions would be unavoidable. Moreover our knowledge is by far too
meagre for such description. Thus in the case of apparently catatonic
symptoms in organic psychoses, we must, for example, first find out
whether and to what extent they are based on the same schizoid
mechanisms as in schizophrenia before we can say in a given case
that the morbid picture is colored by a schizoid disposition. We do
not know the somatic (toxic?) part, that probably conditions the
tendency to euphoria and mania in paresis, and consequently cannot
tell to what extent an induced paretic mania results from the disposi-
tion, etc.
Besides, the diagnosis in the present sense still remains the im-
portant factor. If we formulate our findings in such words as "or-
ganic disease," "''epilepsy," "manic depressive insanity," or "neurosis,"
we have at the same time drawn from it the most important practical
and theoretical consequences, which at least for the present cannot be
substituted by any other theory. What would be the use of recogniz-
ing an hysterical mechanism, if we would not know whether it de-
veloped on a schizophrenic, paretic, epileptic, or on a mere nervous
constitution? And if instead of calling a disease schizophrenia we
would have to describe all the individual mechanisms which we see
acting in unison, we would hardly ever get through, and we would
then still have to keep the whole story in our heads, in order to decide
upon the prognosis and treatment. Also the two latter deductions
could be the same as in any other psychosis, which is composed of
quite different individual syndromes, that is, it would look quite
different in the description, but would become attached to the former,
without anything further, through the diagnosis of schizophrenia.
The first thing to consider in the "Strata-diagnosis" ("Schichtdiag-
* Comp. also the end of Chapter IX on "syndromes," p. 198.
nose") of Kretschmer is the constitution, whereby there is tendency of
late to understand only something acquired through heredity, although

it is natural to suppose that some qualities, as e.g., the weakness of
an endocrine gland, can be just as well acquired as congenital. But

the constitution even in this narrow sense is by no means a factor
acting only in one way. It acts pathogenetically when it gives direct
origin to an amaurotic idiocy, to a schizophrenia, or a manic depressive
insanity; it acts "pathoplastically" (Birnbaum) when as a schizoid
disposition it determines the formation and the kind of delusions in an
organic disease, or when it causes an alternation of manic and depres-
sive moods in the same disease. In the latter case it influences besides
the course of the external morbid picture, and it is assumed that it
can determine the severity of the disease in its manifestation and
outcome.
The concept of disposition includes the constitution and with it
also all the not familiar factors, congenital and acquired, that may
come into consideration, such as poisons, infections, traumas and
physical diseases of various kinds. It acts exactly like the constitu-
tion: pathologically, pathoplastically, and determines the course and
the severity of the disease.
A particularly conspicuous side of the disposition is the character,
which acts pathoplastically; thus certain ideas of persecution and
grandeur are only possible in definite strivings and in definite char-
acterological relations to the environments; the economical person be-
comes miserly in senile dementia.
But by
indirectly the character also acts pathogenetically, not only
assisting in the acquisition of a syphilis or an alcoholism, but also
probably through the fact that certain diseases, like paranoia or even
paranoid conditions, i.e., diseases w^hich are made up, as it were, of
delusions, would not have broken out, if the character would not have
assisted in determining the possibility of delusional formation. The
neuroses too require a soil of a definite character foundation.
However, the character may also be the result of a morbid dis-
position, which later leads to a psychosis (schizophrenia, manic de-
pressive insanity, epilepsy), or it may be the partial manifestation of
the disease (oligophrenia, schizophrenia epilepsy), or it is the disease
that first emphasizes definite features of character, exaggerates, or
caricatures them (a punctual and conscientious person becomes quer-
ulous in old age, the generous becomes thoughtless, and the one who
is somewhat below par morally becomes an unscrupulous criminal as
a schizophrenic).
Quite independent of the disposition, as far as its psychic expres-
sion is concerned, is the part played by individual cerebral processes
which change the material foundations of the psychic life. Among
the first to be named is the diffuse atrophy of the brain, that is, its
cortex, which in very different diseases is the most essential factor for
the structure of the psychic picture of the symptoms and quite inde- ;
pendent of all other manifestations and dispositions determines what

we call clinically "organic mental diseases." In reference to the
psychosis the cerebral alteration acts pathogenetically, while in refer-
ence to the symptomatology pathoplastically. That the localization,
and the kind must exert a forma-
of the process leading to the atrophy
tive influence on the distributions of the picture, which we consider
as accessory manifestations, is self-evident. But as yet we know too
little about it to give these factors serious consideration. The invasion
of the spirochites exerts a tendency to euphoria; certain senile proc-
esses like cerebral pressure determine a torpor of all psychic processes.
Multiple sclerosis (and epilepsy) and other organic brain diseases
dispose one to hysteroid symptoms, while paresis and senile dementia
often cause them to recede.
Circumscribed injuries of the brain also come into consideration
both in regards to causation as well as formation. Lesions in the
basal ganglia diminish the energy from the impulsive life (sleeping
sickness) other lesions at the base of the frontal lobe lead to moria,
;
facetiousness, and a tendency to mischievous teasing. Other circum-

scribed lesions in the basal ganglia determine a labile affectivity, while
all destructions of parts of the brain are likely to produce irritability
and transient moodiness.
Congenital dispositions also influence the form of the symptoms
in these cases, in that the force of the schizoid functions adds to the
picture schizophrenic symptoms, and pronounced syntony manic de-
pressive symptoms; the other dispositions of character also color the
disease. That former experiences, e.g., delusions, can color the organic,
and that poisons (alcohol) can influence the entire psychic picture even
here,is well known.
More difficult is the formation of the theory in epilepsy. The

epileptic process (chemical or anatomical) produces a marked change
in the psyche, but only in the same direction as the epileptoid founda-
tion showed itself before the appearance of the disease in the patient
himself or at the same time in his blood relationship. We shall there-
fore do well here to reserve our theory for a while.
Still more complicated are the relations in schizophrenia. Here
too there is a disposition, which psychically shows itself as an embryo
of the later insanity, then there are elementary disturbances in the
thought apparatus, wliich are still hard to understand, somewhat lat^.-r
or in acute shifts there are distinct organic changes in the brain and
on the top of this as accessories there develops the entire polymorphous
complex of the schizophrenic manifestations, as reactions of a sick
organism, or as deviated functions of the psyche.
Besides the epileptoid and schizoid characteristics, which have
some connection with the disease itself, other qualities of character
must naturally co-determine in many directions the outward appear-
ance of the psychosis.
Some toxins, like alcohol, morphine, and cocaine, act causatively
and at the same time formatively, so that one can tell the cause from
the picture; in their manifestations these poisons are also definite
forms of psychic disturbances.
When different causes producing definite symptom complexes co-
operate, for instance, a spirochite invasion and an alcohol poisoning,
it is customary to view the one disease as the essential and the ad-
mixtures of the other as a "coloring" of the same. In a delirium
tremens we sometimes find the signs of paresis, in senile dementia
those of alcoholism. As a matter of fact, it concerns here a mixture
of two diseases, of which, to be sure, the one without the other would
often not come to light. Similar conditions prevail when only dis-
positions, and not a pronounced disease complicate the main psychosis.
Febrile deliria, and delirium tremens, are influenced by schizoid
factors, schizophrenia by alcoholism, in that, e.g., the hallucinations
and delusions become more united. A schizoid disposition or schizo-
phrenia and the effect of alcohol mix with a uniform picture, in acute
alcoholic delusions, in so far as the tw'o components are even much
less separable than the alga? and fungi among the lichens.
The psychosis or the disposition can also counterbalance the other

in individual symptoms: organic psychoses loosen the blockings and
other catatonic manifestations of schizophrenia. The original char-
acter can be turned into its opposite.
There are also definite syndromes ("diseases") which are produced
by definite On the other side it has
causes or cerebral processes.
been said that similar causes may produce different pictures of dis-
ease, depending on the reaction type of the patient. Thus a fever, an
alcoholic poisoning, a delirium tremens, a paresis, even a manic de-
pressive attack will set free schizophrenic symptoms in a schizoid
individual. Depending on the disposition, psychic influences will
evoke twilight states, hysterical attacks, a neurasthenia, a schizo-
phrenic attack, or chronic delusional formations. The correct concept
is that a disposition and a chance cause manifest themselves in the
morbid picture in just such cases, or, what is the same, that two
causes participate in the formation of the picture.
Individual diseases are direct products of the disposition: they are
nothing but the expressions of the congenital disposition, which mani-
fests itself at a certain age (amaurotic idiocy, process shifts of schizo-
phrenia, arteriosclerosis). We assume that in accordance with fate
the disease would here break out under all circumstances. Neverthe-
less in the individual case some still think of chance causes, which
were necessary to set free the disease, or have at least participated
in some way (reenforcing, hastening the outbreak) in the success of
the disease. Precisely in arteriosclerosis one always looks for external
causes.
Besides, the layman, and even now many physicians still have the
same idea about the appearance of a disease, to which one is predis-
posed, as about the appearance of a running nose through a cold. In
addition, when it is a question of the psychoses one thinks mostly of
psychic injuries. But as far as temporary injuries are concerned,
there is not the least basis in experience for such an assumption.
People who consider it quite obvious that any unfortunate occurrence
"can drive one crazy," and that confinement in the insane asylum
will "surely make one crazy," mistake transient reactions for perma-
nent maladies resulting from dispositions. Only where the harmful
influence permanent can it sustain a permanent reactive psychosis:
is
delusion of being pardoned in life-prisoners, paranoid, or damage suit

neurosis. And when we speak in such cases of a "disposition" for
the concerned diseases, the expression means here something quite
different than the disposition for schizophrenia or for arteriosclerosis,
which in the light of hitherto conceptions is nothing but the germ
of the disease, whereas in the latter examples the disease represents
only an accidental special reaction to a general reactive predisposition.
As to the very different things that are understood by "occasion for
something" ("Anlass"), and what causative and at the same time
formative meanings it conveys, is too familiar to require here more
than a few suggestions. In the vocation of the saloonkeeper there is
the "occasion" for becoming an alcoholic, in the war, for dreaming
or hysterical manifestation, in fever or in a nephritis, there is the
occasion for a catatonically colored delirium, in alcoholism for the
outbreak of epilepsy, in Bright's disease for an amentia, in a fracture
of the head of the femur or in an exhaustive disease for a senile
dementia, and in childbirth for a schizophrenic shift. The latter con-
nection as well as the hysterical manifestations with their causes belong
in the sphere of the psychogenetic, which are not unknown in the
present time; an exaggerated or qualitatively abnormal stimulus in

a corresponding disposition leads to a psychosis or neurosis; the same
happens in the case of a normal stimulus, if the kind or force of the
reactivity is abnormal.
Still more could be said about the "structure of the psychosis";
the material mentioned should show only about what points of view
come into consideration, and how complicated are the various factors
influencing one another. Analogous points of view could also be
considered in the study of the demolition, improvement, and flattening
down of the diseases.
.
CHAPTER Vm
THE RECOGNITION OF INSANITY
In the diagnosis of insanity in general it is hardly ever possible
to obtain in a single examination a complete morbid picture, or to
follow a general plan of examination.^ One would never finish and
would worry or irritate the patient unnecessarily. And only at excep-
tional times is it feasible to keep to a definite procedure in the
examination. When the patient indicates a symptom to us, e.g., an
hallucination, it is usually advisable to follow the trail at once. Often,
too, wê are forced to verify only a few cardinal symptoms and of
the others as much as is still necessary and possible under the
circumstances.
But in this respect one must not be too modest; the more one
knows, the more certain the d iagnosis and the m nrp dpfiTiite-iim-hpTp-
peijtic-Baegûresy^ Theliumah psyche is so complex that much that at\
irst seems a sure symptom of a definite mental disease is not infre-
quently explained as something else when all the circumstances are

known. )^ frequeTitly--suffices^ to make_ oiily-H'e dlHgn o s ia of -4b
disease without, however, ascertaining the particular psychosis.
This is when an excited, or violent, or fasting, or suicidal
the case
patient is committed to a hospital as quickly as possible. The
to be
eventual necessity of a neurological, ophthalmoscopic, and general
physical examination should always be borne in mind.
Since a general examination is not possible as in somatic diseases
where one begins at the head, and ends with the feet, the only thing
to do is to follow up those symptoms which one was called to treat
* Plans for examination

have been devised which naturally take into con-
sideration ever>'thing existing and, for that reason, must give a too large number
of view-points. It may be a good thing for a beginner to read them through
carefully and note ever>'thing that might be considered. But in the examination
itself one must be able to hit upon the selection necessary for the special case,
not only in the interest of the patient, but especially of the physician who
otherwise, as experience shows, easily neglects the important point. This im-
portant point, namely, the examination of the chief symptoms with their theo-
retical and practical associations, simply does not permit of schematization and,
therefore, compared with the remaining trifles in the scheme, necessarily falls
short.
184
THE RECOGNITION OF INSANITY 185
or that immedifitely strike one's eye, and think of those diseases that
can produce such manifestations, and then look around for other signs
of the disease. If the suspicion is neither positively nor partially con-
firmed, then other possibilities will have to be considered. In order
to do this, it is necessary to carry in one's head the symptomatology
of at least the more important individual diseases.
The kind of questioning is of the greatest importance. In the finst
place, if it is at all possible, one must not irritate the patient until
the most important information has been obtained. It is much better
to gain his confidence, naturally without taking him in. An examina-
tion under false pretenses should be avoided. If a patient does not
talk, a physicalexamination can be made, perhaps occasionally, as if
by accident, a question may be put to him as "Does this hurt?" or
something similar and so induce the patient to speak. One can
observe much in both the mental and physical field without the
patient's noticing it; thus one can become accustomed to notice the
pupilary reactions in an ordinary conversation. One will always keep
in mind the whole situation as it appears to the patient. The identical
question with or without introduction may, in one situation or another,
be a very good one, or such that it makes the patient unfit for a further
examination. "How much is twice two?" may be a good question but
under other circumstances it may suggest to the patient another ques-
tion, viz., whether the physician is crazy. A test of the sense of pain
with needle pricks is something entirely different if the patient is
distracted or not, if one dashes at him with the instrument, or first
begs him to indicate whether he notices the prick, etc. In short, in
these matters one must have some practice and above all native tact
and comprehension of the situation and the consequences, otherwise
all special directions and details are useless.
One must never forget that the examination in the clinic,

where the examiner usually knows the patient and where the entire
situation facilitates many questions, is entirely different from the
examination in a first consultation. The latter requires much greater
care.
Naturally, whenever possible, one endeavors to obtain a good
anamnesis. If this is possible before the examination, it can materially
many cases one then needs only
shorten the entire procedure, since in
a confirmation of important data by the patient to be sure of the
its
diagnosis. But even after the examination one must not hesitate to
supplement or obtain the anamnesis, because only now does one know
in all respects the drift of the situation. In this matter one must
not be too gullible. No anamnesis is entirely impartial; purposely or


accidentally with good or bad intentions, a great deal is invented both
on the good and the bad side. One should be especially careful about
an anamnesis which is obtained from the patient himself. Correctly
used, it frequently furnishes an absolutely clear diagnosis despite the
patient's wishes.
Something entirely different from a single examination is a com-
plete examination or observation which is usually necessary in giving
a professional opinion. Here one must be assisted by the other de-
partments which the clinic offers and possibly by other specialists,
such as the examinations of the eyes, ears, blood, fluids, etc. This
technique must be acquired in institutions or at least from textbooks.
Such examinations can usually only be done in institutions.
The intelligence examination will be discussed in the chapter on
Oligophrenia.
If a case is not clear without it and under all circumstances, if
one must handle the patient oneself, a minute physical and especially
neurological examination must not be omitted.
In patients who are inclined to assume tense attitudes or who are
otherwise awkward, the patella reflexes are best taken not with the
knees crossed but with the feet somewhat forward and the whole sole
resting flat on the ground. If they are absent, they can sometimes
be obtained by Buzzard's method, that is, by raising the heels in this
position with the point of the foot left on the ground.
In testing the pupillary reflexes the beginner often makes mistakes.
The directions recommended for avoiding them are contradictory;
clinical experience, one's own good sense, care and adaptation to the
special case must help along.
One does well to observe the pupillary reflexes while conversing
with the patient. In doubtful cases the room should be darkened
and lighted. Restricted sources of light, especially the pocket flash
light, are likely to result in false reactions. Touching the lids is often
responded to by patients with irritability or stubbornness. One should

be careful not to confuse in the insane, light and accommodation
and psychic reactions.
For examination of cerebrospinal fluid see the section on organic
psychoses in general (p. 238).
Clinical experience alone can teach the technique of mental exami-
nations. One must know from observation what a blocking or a rigid
mimicry is; whoever would depend on theoretical descriptions will be
helpless before the patient, or make the Most
crassest mistakes.
psychic symptoms are exaggerations of normal mechanisms; for that
reason one must not only see them, but also evaliiate them. Whether
an affective stupor, a blocking, or a speech disturbance is pathological

cannot be described, and still less whether these matters are patho-
gnomonic of a particular disease. Clinical experience, too, must teach
one to understand the descriptions with the necessary grain of salt.
Words cannot do more than seize upon a pronounced "typical" facies
from the endless variety of psychic manifestations; only observation
can decide to what extent such an example should be generalized and to
what extent not.
As far as the individual functions are concerned, attention should
be called to the following
Whether the patient is oriented, usually shows of itself. When
necessary, a few questions will make for certainty.
Even the layman can recognize sense deceptions usually from some
contradiction with ordinary experience, although in individual cases
one will have to prove the reality of the perceptions. A great many
hallucinations may be recognized by the fact that they cannot be
described in such detail as a perception. Like dreamers, the patients
often hallucinate only what matters to them; they can see a part of
a body, but then rather imagine the person to whom
belongs than it
perceive him. Concerning the voices, the patient at times gives only
the sense; the hallucinator cannot say which of several synonymous
expressions he has heard, or even when he states it positively, he fre-
quently contradicts himself in repeated accounts. Upon exact ques-
t'oning the illusions often are differentiated from reality as "pictures,"
or "inner voices," or something similar. But there are many excep-
tions; the visual hallucinations of delirium tremens are especially
distinguished for their detailed elaboration.
Direct questions concerning hallucinations are frequently incor-
rectly answered in the negative (denial, inhibition) ; with patients
whom one does not yet know, it is advisable to inform oneself indi-
rectly through such questions as "Do you sleep well? Does any one
disturb you? Do the neighbors concern themselves with j'ou much?"
etc.
Similarly in delusions. Where their content does not prove incor-

rect from the first, one should, when possible, test their objectivity.
But this is not the only criterion and, precisely considered, not at all
the decisive one. A
mistake involves also an incorrect judgment, and
a delusion may by chance correspond with reality. It would be really
futile to examine the objective foundation of a jealousy delusion; the
decisive factor is the patient's subjective confirmation of it. If for
his firm conviction he offers no other grounds than that his wife's
bed was once particularly warm, that twice in succession the same
man met her as she was leaving the house, that she looked frightened
when the patient came home unexpectedly, then it is a question of
delusions whether the wife is in reality faithful or not.
In many cases, perception is naturally tested indirectly. One can

easily see whether people see and hear correctly. One will notice
how quickly they comprehend questions, whether one must repeatedly
explain things, and for what reasons. Optical comprehension can
also be tested by reading; especially convenient for this examination
are suitable pictures that are not too large, which one quickly uncovers,
and then must know what may be
covers, but in this connection one
expected from a normal person.
In most cases the associations need not be specially examined;
every conversation, especially when one lets the patient talk, is an
association test. Milder flight of ideas becomes evident, if one stimu-
lates the patients somewhat and lets them tell what interests them.
The association experiments which are ordinarily unnecessary have
to be practised somewhat if one wants to use them.
Memory is already tested in taking an autanamnesis ; many ques-
tions can be put in such a way that they will throw light also on this
function. The memory for happenings in the course of the examina-
tion (impressibility) examined by again asking the patient after a
is
little while what was discussed in the beginning and by having him
repeat examples that have been given him. Isolated numbers of from
four to six digits and rare words or whole sentences very often cannot
be reproduced at once even by healthy persons when they are some-
what excited. At all events, one must make sure that the patients
understood what was said to them and to a certain degree compre-
hended it.
can be examined directly only in very few cases;

Affectivity
one can always see how the patient reacts; furthermore one can
give him an opportunity to show a difference in his reac-
tion to important matters and to trifles, and to exhibit morbid
lability, etc.
For anomalies of the impulses one must usually question, if they
are not indicated in the anamnesis; but perversions like homosexuality
and similar anomalies are often indicated in the whole behavior and
in the dress of the patient.
If in order to test different functions one wants the patients to read
and recount a story, the following illustrations, according to our experi-
ence, are especially well adapted for it, obviously because they contain
repetitions. The first, exacts the easiest and the last, the most difficult
demands:
The Donkey Loaded with Salt

A donkey, loaded with salt, had to wade a stream. He fell down
and for a few moments lay comfortably in the cool water. When he
got up he felt relieved of a great part of his burden because the salt
had melted in the water. Longears noted this advantage and at once
applied it the following day when, loaded with .sponges, he again
went through the same stream.
This time he fell purposely but was grossly deceived. The sponges
had soaked up the water and were considerably heavier than before.
The burden was so great that he succumbed.
A remedy does not do for all cases.
Neptune and the Laborer
A day laborer worked along a stream. By accident his ax fell in
and, as the stream was so deep that he could not get it out, he sat on
the bank and bemoaned his fate to the river god.
Neptune took pity on the man's poverty, dived down and brought
up a golden ax. "Is this yours?" he asked the laborer. The latter
honestly answered "no." Suddenly Neptune dived down again and
appeared before the woodcutter with a silver ax. To this one, too, the
laborer made no claim. For the third time the god dived and brought
up the right iron ax with the wooden handle. "Yes, that is it. That
is the right one. That is the one I lost," the laborer exclaimed joy-
fully. "I only wanted to test you," replied Neptune; "I am glad that
you are as honest as you are poor. There, take all three axes; I
presentthem to you."
The honest man told this story to several acquaintances. One of
these wanted to misuse Neptune's goodness and for this reason he
purposely threw his ax into the stream. Hardly had he begun to
bemoan his fate to the river god when the latter appeared with a
golden ax. He asked, "Is this the one that fell into the stream?" He
quickly exclaimed, "Yes, that and grabbed for it. But Neptune
is it,"
denounced him as a shameless liar because he wanted to deceive even

a god and turned his back on him. With him disappeared the golden
ax and the laborer had to go home without even his own ax.
Honesty is the best policy.
A Miser Trick
The inhabitants of Cufa were considered the stingiest Arabs. Once
one of them heard that in Bassora there lived a miser from whom all
stingy ones might learn something. When he came to him he frankly
confessed the reason for his visit. "You are welcome," said he from
Bassora; "we will go to the market and shop."
They went to the baker. "Have you good bread?" "At your

and white as butter!" "You see," said the
service, gentlemen, fresh
man from Bassora to him from Cufa, "Butter must be better than bread
because bread is compared with butter. We will, therefore, do better
to buy butter."
They went to the butter dealer and asked if he had good butter.
"At your service, butter as fresh and sweet as olive oil!""You hear,"
said the host, "The best butter is compared with oil, this will therefore
be better."
They went to the oil merchant. "Have you good oil?" "Of the
best, lightand clear as water!" "Hoho," said the man from Bassora
to him from Cufa, "according to that water is the best of all! I still
have a whole barrel at home with which I will serve you liberally."
In fact he served his guest nothing but water since water was
better than oil, oil better than butter and butter better than bread.
"Good," said the miser from Cufa, "I did not come here in vain; I
have learned much."
Under certain circumstances one can draw conclusions concerning
attention, impressibility, registering in general, if after the patients
have been some time in a room unknown to them, one has them close
their eyes and then asks them to tell what objects are in the room.
One must never forget to obtain a clear idea of the attitude of the
patient toward the examination. Some errors are not due to inability
but to emotional stupor, indifference, negativism, and ill will. Char-
acteristic of embarrassment in examinations are answers in which
the given material is mixed up, as when in figuring, single figures in
the problem are put into the answer, etc.
Moreover, neither in the diagnosis nor in any other examination
must the totality of the objective and subjective conditions be over-
looked. In the complicated psychic mechanisms the identical mani-
festations have under different circumstances an entirely different
significance. Senseless delusions indicate in the clear average patient
an existing dementia, but not in the oligophrenic, or in the delirious
patient. Somatic hallucinations only when accompanied by clear
mindedness are sure to demonstrate a schizophrenia. Catatonic symp-
toms in acute conditions becloud the prognosis little, in chronic condi-
tions they have a bad significance. A "rigid" affect may indicate an
examination stupor or schizophrenia. "Negativism" in a sensitive
person may be the result of the physician's demeanor or of some other
part of the situation. A delirious patient with whom it is difficult to
establish a relationship is, us a rule, a schizophrenic or he has epilepti-

form attacks. But in exceptional cases such behavior may be a
symptom of a light delirium.
Such a patient who days showed an otherwise typical
for the three
alcoholic delirium turned his back on us, gave either no answer or
short, rejecting ones. He was a vagrant of rather exaggerated
joviality, who had often been locked up for trifles and considered such
measures as unjustifiable, especially too, his commitment to the clinic
because they had lied to him about it. In the mild development of
the delirium he was conscious of these circumstances, and on account
of which fact he later explained his reaction.
Some psychic symptoms also occur in diseases which we do not
describe here, such as fevers, traumata, heart diseases, uremia,
eclampsia, and similar diseases. What is still more important is this:
one must never expect the reverse, namely to see in a given moment
all theimportant symptoms of a disease. One must never, for example,
conclude that if there is no affective disturbance, therefore it is not
a case of Schizophrenia. Indeed under certain circumstances even in

a pronounced psychosis one can temporarily find nothing morbid. A
negative finding without prolonged observation, therefore, never proves
that the patient is normal; it only indicates an absence of proof of the
disease.
Simulation and Dissimulation. Simulation of insanity is not
nearly so common as the layman supposes. Those who simulate in-
sanity with some cleverness are nearly all psychopaths and some are
actually insane. Demonstration of simulation, therefore, does not at
all prove that the patientis mentally sound and responsible for his
actions. The decision as to whether there is simulation must in most

cases depend on the evidence of the absence or presence of inimitable
symptoms. Those who have not had long experience in hospitals for
the insane, and present a consistent morbid picture, rich in symptoms,
are not resorting to simulation. If the deception is not readily trans-
parent, observation in an asylum must be required in order to '"un-
mask" the person.
is, moreover, proven by inconsistencies, clumsy exag-
Simulation
gerations,and by a representation of a morbid picture, that exists only
in the layman's imagination (Beware of unconscious simulation as in
the Ganser and buffoonery syndromes, puerilism, etc.). A supposed
insomnia can be controlled by watching the patient at night. Ex-
citements that entail exertion cannot be continued very long because
of fatigue; in thrashing about with or without convulsive movements
the simulator plainly takes care not to hurt himself, etc. One can
also suggest that this or that symptom that belongs to the disease is
lacking, whereupon the simulator usually hastens to complete the
picture. These are a few indications. All details cannot be described,
as one would have to repeat the entire symptomology from this ôint
of view. A very thorough uninterrupted observation, if possible both
by day and night, is important. On the one hand this will tire the
simulator and, on the other, it will usually produce many evidences
of the attempted deception. The first glance often arouses a suspicion
of simulation when one notices that the patient who has just been
admitted acts in an excited and confused manner and at the same
time attempts to orientate himself by glancing about and following
carefully everything going on around him.
It is more difiicult to judge simple exaggerations in psychopathic
or even insane people. Here, too, the line of demarkation between
conscious simulation and disease is as faint as in the case where the
unconscious acts the part, e.g., in the Ganser syndrome. At times,
therefore, one cannot decide how much of the "simulation" is conscious
deception and how much emerges from the unconscious as a product
of the disease.
Much more frequent than simulation one observes dissimulation
of a mental disease. Melancholies make it appear that they are cured
in order to carry out suicide; other patients, so that they will not be
limited in their activities or to obtain an opportunity for carrying out
their plans, etc. This dissimulation on the patient's part is, naturally,
only a concealment of thoughts and symptoms which they know others
regard as signs of insanity. For they themselves do not consider
themselves sick.
CHAPTER IX
DIFFERENTIAL DIAGNOSIS
In differentiating the psychoses one has to keep in mind that most

of the individual pictures of conditions and syndromes may occur in
different diseases; one must therefore look in addition to these for
concomitant specific symptoms and for specific shades of the syndrome.
None of the diseases have specific symptoms and except perhaps
from the course they take, they should therefore be diagnosed
only by the careful exclusion of other diseases ("negative diag-
nosis"), such as manic depressive insanity, paranoia, hysteria, com-
pulsion neurosis, and the psychopathic conditions. Specific symp-
toms of amentia, uremia, and many other rarer diseases are not yet
known.
In the differential diagnosis also one cannot expect to find at any
particular moment all the differentiating characteristics; and there,
too, nearly allsymptoms are to be valued only in connection with the
psychic environment. The psyche offers so many possibilities that
through a chance constellation a symptom of one disease, considered
specific, may sometimes be imitated by another. Our language, even,
cannot cope with the wealth of manifestations and must designate
different things with identical or similar names; the pressure activity
in mania, in presbyophrenia, in paretic and several other organic
dehria, and that in delirium tremens, are of entirely different varieties
and cannot be differentiated by brief designations.^ Whoever follows
diagnostic catch words without paying attention to constellations and
nuances will go wrong any moment.- Also the diagnostic observations
in the special part of this book make no claim to completeness but
emphasize only that which might be insufficiently stressed in the
symptomology of the disease, especially in the diagnosis. The essen-
tials for the diagnosis must be gathered from a knowledge of the entire
disease. The following remarks, too, are only to be utilized in this

sense.
^ In many twilight states, too, and in erethic idiocy there are syndromes which
could be called pressure activity.

'
Cf also footnote,
. p. 84.
193
COMPILATION OF THE DIFFERENTIAL DIAGNOSTIC

SIGNIFICANCE OF INDIVIDUAL SYMPTOMS
^
Disturbances of Perception
Sense perception is retarded and often falsified in the organic

psychoses, and in a very similar but not identical sense in epilepsy;
in alcoholism it becomes inexact, but no retardation is seen when tested
without apparatus. In all cloudings of consciousness it can be dis-
turbed in various ways.
In jorms of idiocy the synthesis of combined impressions is affected;
the patients see and comprehend the unit but cannot work it into a
complete picture. At times the meaning of simple pictures is not
recognized, even perspective is not understood.
Real illusions may occur everywhere, and are especially prevalent
in clouding of consciousness.
Of the hallucinations those referring to sight usually preponderate
in disturbances of consciousness such as delirium, twilight states, etc.;
in mental clearness they are rare.
In chronic conditions of schizophrenia accompanied by clearness
auditory and somatic hallucinations predominate; under these circum-
stances the latter are characteristic of the disease. Hallucinations
and illusions of smell and taste occur especially in schizophrenia, but
also in delirium tremens, and in various twilight states.
Characteristic of delirium tremens are in the first place tactile
hallucinations, then the numerous visual hallucinations, which are
multiple, moving, and mostly colorless, often representing particularly
small or diminutive objects, especially animals. Along with visions
of this sort the patients frequently feel and see threadlike objects,
wires, ropes, spittle, and streams of water. Auditory hallucinations,
in pure delirium tremens, have noticeably often the character of
music, which is otherwise rare. If verbal auditory hallucinations are
prominent, it is a question of complications, especially with schizo-
phrenia or with alcoholic insanity.

Auditory hallucinations of a dramatically connected character that
refer to the patient in the third person indicate with great certainty
abuse of alcohol and occur in acute alcoholic insanity and in alcoholic
schizophrenics.
Microscopically reduced hallucinations of sight and touch belong
to cocainism. In sniffing cocainism, one frequently observes tangibly
distinct voices, visual illusions, and vividly colored visions.
' Cf . also p. 56.
DIFFERENTIAL DIAGNOSIS 195
In manic depressive and in organic psychoses, visual and auditory

hallucinations are most common. In organic patients they are much
more frequent at night than in the daytime.
Visual and auditory hallucinations in themselves have no specific
significance; they are the ones that may occur in every mental
disturbance.
Disturbances of Association
Flight of ideas occurs in the different manic states, at times in

exhaustion, otherwise hardly ever; thus in epileptic excitements it is
extremely rare.
Inhibition of associations, retardation and inability to rid oneself
of a sad subject which may run to monideism is a partial manifesta-
tion of the various depressive states. Other form-s of retardation of
thought may occur in various diseases such as brain pressure, organic
inertia, and toxic states.
In schizophrenia and under certain circumstances also in hysteria
we find blockings as an exaggeration of a mechanism that occurs
in every healthy person; moreover, some or all of the influences
that otherwise guide associations are often lacking, which results
partly in bizarre, and partly in entirely disconnected chains of
ideas.
In epilepsy ideation is slow and hesitating, the mental content be-
comes restricted to the ego, there is an inclination to affective colored
associations especially to those containing judgments of value, and
further to perseverations, tautologies and to circumstantiality in par-
ticular; the patients do not easily get rid of a subject without thinking
it out in many directions.
In organic conditions, too, there is a tendency to perseveration and
there is frequently a retardation of all reactions. But more important
is the restriction of the number of ideas simultaneously possible.
Especially readily absent are those ideas that contradict an actual pur-
pose, whereby organic dementia is most strikingly characterized.
In oligophrenics the range of associations is also limited but what
;
is lacking belongs to the complicated associations, the attainment

of which requires a higher psychic activity, and to those that are
extraordinary. The patient thinks of what is plain, tangible and
ordinary.
In paranoia, and in a certain sense in hysteria also, some associa-
tions are facilitated and others are inhibited, according to whether
or not they harmonize with the purposes that are interwoven with
the disease. Aside from this there are no anomalies of association.
Disturbances of Orientation
Orientation as to place and time is disturbed in advanced organic

mental diseases, and generally in delirious and twilight states of all
kinds. In schizophrenic twilight states correct orientation often exists
with the falsified. The other patients know where they are and what
time it is, unless chance circumstances falsify these concepts.
Orientation as to situation is as a rule naturally also incorrect if
place and time are registered incorrectly; but in addition it may be

disturbed in every hindrance to judgment, or as a result of manic
ideas or similar anomalies.
Autopsychic orientation, the personality with its relation to the
family, occupation, dwelling place, etc., is most readily falsified in
paresis and dreamlike twilight states. It is striking the way it
in
remains intact in the deepest delirium tremens, while an apparently
sensible paretic or a schizophrenic readily declares himself to be the
emperor or a particular saint.
Disturbances of Memory
In chronic alcoholism the memory becomes inexact; katathymic
memory whose content apparently is not far removed from
illusions,
reality, are not rare. In dementia alcoholico-senilis and in Korsa-

koff's disease there an organic memory disturbance. After
is also
delirium tremens remembrance is incomplete and very inexact; after
uncomplicated acute alcoholic insanity it is good. After pathologic

drunkenness there is usually amnesia. The tendency to phantastic
stories is heightened in delirium tremens to confabulation-like excuses,
and to real confabulations.
The memory of the organic group is characterized by an especially
marked, or exclusive confusion of the more recent memories. The
void is often filled by provoked (perplexity), or spontaneous confabu-
lations. Amnesias after dehria, and confusions are not rare even
after mere excitements.
The schizophrenic memory retains all experiences; but blockings
and other affective reactions in a given moment very often make it
impossible for the patient to utilize his engrams. As there is no elabo-
ration of perceptions in certain chronic stages, the schizophrenic
memory often retains insignificant details better than does the normal
memory. Memory hallucinations and katathymic illusions are
frequent. In spite of the frequent occurrence of deliria and'
twilight states amnesias are rather rare, and still more rarely are they
complete.
DIFFERENTIAL DIAGNOSIS
197
In epilepsy the memory becomes

unsystematically poor. Complete
or partial amnesia an ordinary occurrence after twilight states.
is
Hysteria at times very markedly transforms memories in accord-

ance with the momentary affective requirements. After twilight states
amnesia is apt to be complete, but it is relatively easy to remove it
by suggestive influences.
In the paranoiac, memory illusions, combined with the morbid self-
reference, form the most important foundation of the delusions.
In oligophrenics memory varies greatly. All things being equal,
the incomprehensible is naturally retained less readily than the com-
prehensible, and the patients understand poorly the very things that
appear interesting to the normal; but hand in hand with this there
is often a noticeably good reproduction of unelaborated material.
In conditions of melancholia the past life is readily explored for

sins. Small errors are transformed into unpardonable crimes; if
none are found, they are invented as a sort of memory hallucination
or memory illusion.
Even during manic conditions but very noticeably after them, the
morbid behavior of the patient is later readily justified through trans-
formations in the memory and by
putting the blame on the environ-
ment. During and after confusions seldom accompanied by flight of
ideas, the memory is very incomplete.
Amnesias are to be expected after all disturbances of consciousness
and after transitory psychoses generally, that is, after hysterical and
epileptic attacks and twilight states, confusions of all kinds, toxemias,
especially drunkenness. After similar conditions of schizophrenia (twi-
light states, hallucinatory states with dreamlike episodes), memor\' is
not always defective and when it is, it is usually only partly so.
Amnesias as to content referring to events, the recollection of which
is at the time disagreeable, are frequent in schizophrenia and hysteria.
Affective Disturbances
The affectivity is labile in organic patients, in alcoholism, in hys-
teria, and in the later intervals of many manic depressive cases.
Acute displacement of the affective attitude (moods) in the sense
of manic or melancholic appearances is seen in alcoholism, in the rather
uncommon alcoholic melancholia, in organic psychoses, in schizo-
phrenia (very common), in epilepsy which is of brief duration and
also shows the very common irritable depression, in manic depressive
insanity, in hysteria, in all kinds of psychopathic states, especially in
the cyclothymias, and in oligophrenics wîere it is as a rule of short
duration and often manifests irritable moods.
The organic affective disturbances regularly show lability, acces-
sory moods, which are preponderatingly manic in paresis and melan-
cholia, especially in the senile forms. In alcoholic Korsakoff's dis-
ease besides lability, there usually is also a euphoric basal mood, which
is not apt to disappear until the later stages of crossness and irritation.
In schizophrenia the affects cease to function altogether in severe

cases; in milder cases affective reactions sometimes appear and some-
times not; when they are present, they are often rigid. At times
they are absent just at the most important events, whereas trifles
are normally accentuated. In many cases irritation up to the stage
of unbounded rage is the only reaction which one sees for a long time;
in mild cases irritation may be the only striking symptom. Para-
thymia and paramimia are not infrequent. Ambivalence is nowhere
so conspicuous as in schizophrenia. Besides these, one also sees mel-
ancholic and manic affective fluctuations.
In the epileptic the affects are easily stirred, readily attain an
abnormal intensity but last abnormally long. At the same time they
are massive and not finely differentiated. Fitful moods of an ir-
ritated, depressive or euphoric character are probably never lacking.
The manic depressive patient in the interval between manic
or depressive attacks often has lability of the affects or lasting states
in the sense of milder manic or melancholic moods.
In hysteria one sees slight outbreaks during which there is heighten-
ing and falling off of the affects. Reactions to similar stimuli are
quantitatively and also qualitatively different, depending on chance
intervention.
In paranoia the affective state corresponds to the content of the
real or delusional experiences. The affective anomalies that must lie
at the root of the disease cannot yet be described more minutely.

Among oligophrenics there are excitable and torpid types; briefly
all we see in normal and psychopathic per-
the variations occur that
and only when possible they run within wider limits. Besides,
sons,
many cases evince the same moods as epileptics.
In all forms of dementia there is a tendency to outbursts of anger.
Some Special Syndromes

States of stupor occur most frequently in schizophrenia, next in
epilepsy, hysteria, and besides in melancholic states, in the mixed
states of manic depressive insanity, and in paresis.
Tivilight states are seen in epilepsy, hysteria and in schizophrenia,
occasionally perhaps in manic depressive insanity, then in the various
toxic states (as in the pathologic drunkenness), in states of ordinary
DIFFERENTIAL DIAGNOSIS 199
sleep (somnambulism,
etc.), following cerebral concussions and hang-
ing, in very severe migraines, and even as states of excitement of
purely affective origin in psychopaths (jail outbursts, fugues, etc.).
Symptoms
of the Catatonic type. Symptoms which from their
external appearance must be designated as catatonic,"* besides oc-
curring in schizophrenia appear also in the organic psychoses; further-
more catalepsy is not rare in epilepsy and is also said to have been
noticed occasionally in hysterical twilight states, in oligophrenia, and
in manic depressive insanity. Something, that must be called echolalia
in spite of an apparently very different origin, besides occurring in
schizophrenia and the organic psychoses (very rarely) appears also
in epilepsy, hysteria, and oligophrenia.
Epileptiform attacks, besides occurring in the epilepsies appear in
schizophrenia, paresis, presbyophrenia, some forms of arteriosclerosis,
alcoholism, including delirium tremens, as affective epilepsy in psycho-
pathies,and outside of psychiatry, in all coarse cerebral diseases, in
uremia and eclampsia.
Paretic-like attacks occur in all coarse brain diseases, especially
when they involve the cortex.
Compulsive ideas and eventually compulsive impulses we see rather
frequently besides in the independently considered compulsion neurosis
and compulsion psychosis, also in schizophrenia, but pretty rarely in
the various depressive states.
Uremia may also simulate the psychic symptoms as well as most
physical symptoms of an organic brain disease or of epilepsy.
Eclampsia, too, may for a short time act exactly like epilepsy.
* Cf . p. 153.
CHAPTER X
CAUSES OF MENTAL DISEASES
I. Germinal Predisposition. It was always known that mental
diseases converge in one family and lack in another, and that in the
families with mental diseases the members that are not really dis-
eased very frequently show certain deviations, which often run in the
direction of the disease. To be sure those families are rare which on
careful search prove entirely free, and the cases with only a few
diseased members are always the more common. Nevertheless the
family predisposition is surely one of the most important deter-
minants for the development of mental diseases.^ To be sure a pre-
disposition alone need not find expression in disease, even when it
undoubtedly shows itself in the particular individual through minor
deviations from the normal and through transference to the descend-
ants. Either there are different grades of hereditary predisposition
or the predisposition does not "develop" in all into a pronounced
disease, or both cases may occur. Besides, we have to presuppose
some predispositions which in themselves are not diseased but still
form necessary or at least furthering determinants in the development
of exogenous diseases: Not every inebriate becomes a "psychic"
alcoholic and not every luetic becomes paretic; but certain psychic
peculiarities that are discoverable in most candidates for alcoholism
and paresis and their families indicate that inherited factors play
a role even in exogenous diseases.
Formerly it was necessary to assume a general neuro- and psycho-
pathic family predisposition that might express itself in the most
variegated nervous and mental diseases and psychical peculiarities.
But since KraepeUn taught us to recognize natural boundaries be-
tween several clinical pictures, the concept of psychotic heredity be-
gan to be more and more clearly divided into several predispositions,
among which may be mentioned in the first place the big groups of
schizophrenias, epilepsies and manic depressive insanity. A part of
^
The conspicuous significance of predisposition shows itself especially in the
insanity oj twim where occasionally both members become sick at the same time
and with very similar symptoms, and what is more, that may happen even when
they do not live together.
200
CAUSES OF MENTAL DISEASES 201
the psychopathies as well as most of the neuroses proved tcj be the

lighter and simpler forms of these hereditary- groups.
Very recently the attempt was made to apply the Mendelian laws
to the hereditary mental diseases and endeavor to make it probable
that these are transmitted recessively according to the Mendelian
type. But the theoretical and practical difficulties are far too great
to have produced something useful so far. We are far from under-
standing what is involved. With the endless shades of morbid pre-
dispositions, from the slight peculiarity of character up to the most
pronounced insanity, it is out of the question that the predisposition
to a psychosis or even the disease itself should be a plain indication
that can be present or absent only as a whole; rather say we would
that at present we cannot assumption of a
dispense with the
mechanism, which may be provisionally designated as "intermediary
heredity." ^ Furthermore the small number of children and the long
duration of a generation increase the difficulties of the survey in
these studies to a particularly high degree.
Besides these lasting family predispositions "Degenerations" are
spoken of. The term designates very different but very vague ideas,
and most observers are so little conscious of this that they do not at
all express themselves about it, but secretly permit one meaning to
pass over into the other, or suddenly substitute one for the other.
These concepts may be arranged into four classes, two relating to the
family, and two to the individual:
1. assumed that some families degenerate through the differ-
It is
ent generations, that they become more and more incapacitated and
generate severer forms of mental diseases, until they die out. Morel
even supposed that this occurs so regularly that it was possible to
prognosticate definite diseases for each of the last four generations.
As a matter of fact there is really no such regularity and we cannot
say anything worth while either about degeneration or regeneration.
Furthermore the Mendelian conceptions which are clear and hold good
for certain conditions present an insurmountable opposition to such
views. In more recent times morbid predispositions were progressively
(not regularly) produced, throughout generations, by means of poisons.
2. It has also been customary for some time, regardless of the
progressi"'-eness of the predisposition, to designate families in which

insanities are very common, as degenerate, especially if the healthy
members also show striking peculiarities.
3. Depending somewhat on this concept, constitutional peculiarities
' Bleuler, Mendelismus b. Psychosen spez. bei der Schizophrenia. Sheweiz.
Arch. f. Neurologie und Psychiatric. Vol. I. Ziirich 1917.
in the individual are designated as "degenerative," in which case
usually the impression is made as if a definite concept were being
used. But actually the most different deviations from the normal in
all directions are so designated, provided they are not included in

one of the familiar morbid pictures.In this sense all families bur-
dened with heredity and their individual (abnormal) members are
degenerates.^
4. There are also degenerative psychoses that are again divided
into two very different classes: (a) those that show the characteristics
described in classes 2 and 3, that develop, or are supposed to de-
velop from an abnormal constitution (Paranoia, "periodic forms"),
or where serious peculiarities of character are observable as causes
or concomitant of the "real" morbid picture (degenerative hysteria),
(b) Such diseases as have the tendency to "degenerate" i.e. they
show a tendency gradually to become worse, to degenerate into de-
mentia as seen in our schizophrenias so far as they really merge into
idiocy.
One should avoid working with such an ambiguous conception as
degeneration and its designation. The concept of degeneration would
most readily fit blastophthoric conditions, the most marked develop-
ments of which we call teratologic, and the milder forms perhaps
might include all kinds of predispositions even those of psychoses.
Families with many abnormal members like those abnormal in-
dividuals mentioned in class 3 we call psychopathic; those with a
tendency to definite mental diseases like those mentioned in class i,
or with less pronounced peculiarities in the sense of a psychosis we
name accordingly manic depressive, schizoid, or epileptoid families.
Race is an important consideration for the origin as well as for
the formation of the diseases, even though at presentwe know very
little that is definite about it. The we find
great number of insane
in the present culture races; but whether, and to what extent, more
insanity occurs, or more remain alive, and how much the damaging
influence of natural selection amounts to, has not yet been investi-
gated. Many peoples, notably North Africans, Abyssinians, South
Slavs, Turks, and Australian aborigines, are entirely or to a high degree
immune to paresis, although syphilis is common among them. Still
our ancestors more than four generations ago were also apparently
immune and, on the other hand, the Japanese who are far less
closely related to us are now as subject to paresis as we. The more

or less extensive use of alcohol does not explain all these differences.
Dementia precox, epilepsy and idiocies also seem to occur in lower
' Magnan's idea of degeneration is a combination of 2 and 3.
races as with us, the first, to be sure, in somewhat different forms.

Kraepelin observed among the Malays an absence of the catatonic
forms; I could ascertain the same among negroes and Indians as
far as modes of appearances are concerned that could be observed
as pronounced catatonias on just walking through institutions and
in questioning physicians and head nurses. The same may be said
here of suicide, whereas just the Germanic race and especially the
Saxons are very frequently victims of suicide. It is said that Jews
are especially predisposed to manic depressive insanity and psycho-
neuroses. According to a very experienced older psychiatrist they
did not develop paresis until they took to "Christian customs and
Christian champagne"; in general, race and manner of living, that is to
say culture, are difficult to separate.*
II. Blastophthory. It seems that even with sound parental pre-

disposition the germ may be so damaged in its development that the
descendant becomes (mentally) diseased. Such influences are ascribed
especially to debilitating diseases, poisons (alcohol!), and infections.
But in the last, among which syphilis comes into prominent con-
sideration, one cannot properly separate the transference of the dis-
ease to the child from the germinal damage. In this field many
assumptions are opposed by a few definite facts.
III. Germ Fusion. There are a few cases that seem to prove that
an unsuitable fusion of healthy germs ("germinal enmity") can gen-
erate diseases; thus a couple produced only microcephalics, while
each of the individual parents had healthy children with another
mate. Also marked differences in the character predispositions of
the parents make themselves felt, according to all we know, in a cer-
tain lack of equilibrium in the descendants. To be sure, in individual
cases this may become the foundation of, and the impulse to. great
achievements, especially the artistic; generally it is nevertheless an
unpleasant supplement to life and one that readily erupts into the
neurotic. The intermingling of races, even those closely related,
often has worse results although, at least according to superficial
still
observations of masses, the West Indian negroes, in whom a white

streak is easily noticed, are a tribe so capable of enjoying life and
so unburdened with any sense of responsibility that one may well
ask whether it is not we who constitute the unsuccessful variety of
humanity.
Relationship between parents (inbreeding) is also much feared.
But it turns out that, in spite of the experience of animal breeders,
who have to reckon with many more generations, that under human
*See below, American Negroes.
conditions injury through intermarriages is not demonstrable unless
there a summation of a common predisposition to disease in the
is
vulgar sense, or a cumulation in the Mendelian sense. In Incas, the

Pharoahs, the Ptolemys, propagated themselves through numerous
generations by marriages between brother and sister, and an inter-
marriage within a healthy family in every event offers better chances
than the intermingling of doubtful or perhaps diseased foreign blood.
Nevertheless, in view of the many cases of deaf mutism and
of optic atrophy observed in intermarriages as well as the experi-
ences with animal breeding it behooves one to observe a certain
caution.
IV. Foetal Diseases. The embryo, too, may be harmed by dis-
eases of the mother, lack of room in the pelvis, by traumatic occur-
rences, as well as by intrauterine diseases, so that it comes into the
world as an idiot or psychopath. To what extent psychical influences
on the mother harm the foetus, has not been scientifically determined.
Undoubtedly sorrow and other chronic depressions may disturb nutri-
tion; and a psychic
shock perhaps through a spasm of the uterine
vessels
may be noticed by the foetus to such an extent that it may
find a vent in wild movements with change of position whereby in-
juries of various kinds are conceivable.
The categories I to IV are often designated as "endogenous causes.'^
But only I, the pathological germ predisposition, is really endogenous;
the remaining, at least in relation to the family, are exogenous, and
in relation to the individual they may be called what one pleases.
In studies of heredity all four categories were hitherto usually thrown
together. It is very important for future research that this should
no longer be done.
If all people were designated as "burdened" who have among their
blood relations (parents, grand-parents, children, brothers and sisters,
aunts and uncles) members who suffer from mental or nervous diseases,
alcoholism, apoplex>% abnormal character or have committed suicide,
then according to Diem ^ 67% of the healthy and 78% of the insane
who are admitted to institutions are burdened. But the difference be-
comes greater, if one counts only those burdened with insanity
(7: 38%) or with abnormal characters (10: 15%) and still greater, if
these categories are supplied merely to the direct burdening (through

the parents), since only 2% of the healthy have insane parents as
against 18% of those who are mentally diseased, and 6% abnormal
characters against 13%. Apoplexies and nervous diseases are observed
" Die psychoneurotische Belastung der Geistesgesunden und der Geistes-
kranken, Arehiv. fiir Rassen-und Gesellschaftsbiologie 1905.
less frequently in the families of the insane than in those who are
healthy.
Nowadays heredity is talked about too much, although in prac-
tical affairs it is not often considered. Many people actually make
life hard for themselves because on account of a hereditary burden
they are afraid of getting sick or being sick. As a matter of fact,
families in which the majority of the members are sick are rare.
Furthermore a sort of regeneration is possible, even though we do not
feel at all clear about this term, and above all the difference between
those considered burdened and those considered healthy is not so
great, because on careful examination abnormalities are generally to
be found also in the latter. It should not be forgotten, also, that many
diseases have no hereditary significance, as for instance most acquired
forms of idiocy and paresis. Furthermore, a sick member of an other-
wise healthy family is usually less dangerous even as a patient than
a relatively sound member of an otherwise heavily afflicted family.
In the former case the exception may be determined by an acquired
disease, in the latter it may represent a chance aberration upwards;
both variations are not true to kind. For questions of eugenics
Forel described the risk as follows: that a family in which in-
sanities occur, but which in spite of this maintains itself, is not to be
feared; while members of a declining family should not marry or be
married.
V. The exog-enous causes affecting the individual sometimes
create disposition, sometimes they precipitate the disease either as a
necessary consequence (carbon monoxide) or as the cause (psychic
reasons), or as one of the various necessary conditions of the disease
(sypKilis in paresis). It is furthermore to be kept in mind that
while individual causes frequently produce definite morbid pictures,
(e.g. traumatic neuroses; alcoholism, paresis) nevertheless, depend-
ing on the disposition and the constellation of other contributing
conditions, the identical (major) causes may generate and occasion
different morbid pictures, such as different traumatic neuroses, hysteria
and neurasthenia in certain conflicts, and various alcoholic forms. The
same psychic influence may release a schizophrenic attack in one per-
son, a neurosis in another, a manic attack in a third. Furthermore,
depending on the disposition the cause may be indifferent, thus a
woman predisposed to cyclothymia can become manic through a
psychic influence or through a childbirth, and the epileptic disposition
can probably be developed into pronounced epilepsy just as well
by a trauma as by alcoholic poisoning. It can be seen from the
illustrations that no decided distinction is to be made between causa-
live and merely precipitating conditions but we must understand that
;
it is a different matter when a fright neurosis or carbonic oxide

poisoning develops in a healthy person than when the disease becomes
"manifest" through a psychic influence, in a latent schizophrenic or
manic depressive patient. But intermediate cases make it impossible
to carry out a sharp separation.
Among the exogenous causes discontinuation of soothing with the
natural nourishment is to be mentioned also,*^ although here, too, we
should like to know something more definite.
Moreover all diseases are to be considered that directly affect the

brain, such as traumata,and in childhood above all polioencephalitis
and meningitis, which create oligophrenias, psychopathies, epilepsies,
and organic diseases. Scleroses, tumors, and other brain diseases
cause different pictures. Infectious diseases may change the anatomical
consistency of the brain, as cerebral lues, paresis, encephalitides, and
lyssa, or they may affect its function through poisoning as in fever
psychoses, and in the forms of "delirium acutum," or they may in-
directly disturb its nutrition as in syphilitic diseases of the blood
vessels. Besides the fever psychoses, infectious diseases can probably
precipitate schizophrenic "shifts."
Other physical diseases which in respect to the brain may be called
exogenous not seldom cause mental diseases; carcinomatous dyscrasia
and perhaps stomach and bowel disturbances can also produce states
of confusion; diabetes seems to favor depressions; through the neuritic
processes in the brain it can bring about Korsakoff's syndrome, and
through acetone poisoning delirious conditions. Of course, diabetes
is also frequently only a parallel manifestation of the mental disease,
e.g. in organic brain diseases. Hypo-function of the thyroid gland

causes myxedema and cretinism; a certain complicated hyper-func-
tion causes Basedow's psychoses. The other glands are also connected
with the psychic, but they are very far from being suflBciently
understood.
Of the external poisons alcohol is to be particularly mentioned. It
is responsible for 20 to 35% of the male admissions to the hospitals,
and probably makes alcoholics of 10% of the men outside,'^ but it also
complicates, co-determines, or aggravates other psychoses, especially
epilepsy, traumatic neuroses, and paresis.^ A similar even though
numerically a vastly minor role is played by ether, opium, morphine,
* Bunge, Die zunehmende Unfahigkeit der Frauen, ihre Kinder zu stillen. 7.
Aufl. Rheinhard, Miinchen 1914.
' Schweizerische Statistiks. Sanitarisch-demographisches Wochenbulletin, 1903,
und Internationale Monatschrift zur Bekaempfung der Triiiksitten, 1904, p. 183
'The influence on posterity was discussed in Part II.

and Other poisons that enter into consideration here are

cocaine.''
lead,carbon monoxide, pellagra and ergotine. Sonie also wish to
blame here tobacco, which is probably an unjust view. Lack of vita-
mines acts like the poisons, as in the case of Beri-beri.
Among other diseases those of the sense organs, especially that
of hearing, are to be mentioned ; the latter do harm rather through their
psychic influence. Thus paranoid distrust and irritability result from
defective hearing, heart and vascular diseases occasion anxiety states
and atrophies of the brain, while kidney diseases are often at the
foundation of amentia.
Exhaustion ^ also is said to produce insanities ; there is no doubt
that hunger in its last stages causes deliria. That over-work, which
is frequently mentioned may bring on mental diseases, is not to be
assumed; it usually conceals politely our ignorance of the causes,
a good physician works much more than most of the patients that come
to him because of over-work. It is more proper to assume that the
congenital "morbid exhaustiblity" expresses the predisposition to
psychoses. But usually it is emotional difficulties that "exhaust the
nervous energies," or the slowly advancing schizophrenia deludes the
patient with a feeling of exertion and over-exertion. Among ten thou-
sand Serbs captured in the late war, who were all subjected to the
most miserable state of maximum over-exertion and severe under-
nourishment, only five became insane. Therefore, acute physical
exhaustion, _at least, may be crossed off the list of the causes of
psychoses. Weakness from acute loss of blood is also not a cause of
psychoses, according to statements that I have received from surgeons.
Among mentioned; but as yet
living conditions climate should be
we do not know its Concerning the so-called Tropical
influences.
mania which is naturally a collective term for different things, it is
not even certain to what extent it is really brought on merely by
the heat, and to what extent by the use of alcohol and by other
diseases, and by the feeling of being absolute master of life and death
among savages (a sort of Caesar mania).
Occupation may cause poisoning, thus employees of the alcohol
industry readily become alcoholics, and persons occupied with the
healing art become morphine addicts. In the army many psychopaths
succumb to disease from exertion than from psychic causes. Some
less
occupations, such as school teaching and acting, are said to dispose
' Most recently the use of cocaine in the form of snuff powders is ver>-
rapidly gaining the ascendencj' with the demi-monde and its associates.
"According to Kraepelin exhaustion is the excessive consumption or insuf-
ficient replacement of the active substances, while fatigue is the accumulation
of waste matter that has a paralyzing effect.
people to mental diseases. But what is more likely to be the case is,
that affected or rather psychopathic people show a preference for

certain callings, just as no occupation or tramping is selected only
by morbid or insane individuals.
According to the classification of civil conditions there are a great
many single persons among the insane, and it is plausible that the
more regular life of the married, in sexual and other respects, is a
slight protection against disease. But it should be remembered that
half of all the patients, the oligophrenics, cannot marry because of
their disease; and the same is true of those schizophrenics who are
afflicted w^hen young. Other abnormal individuals do not marry be-
cause of various psychic reasons, and people who are divorced are
ver>^ often not normal. Thus there remain only the widows and
widowers that could demonstrate the danger of being single and it
is really said that the latter become sick more frequently than the
married.
According to experience civilization, so called, is one of the most
important breeding places of mental diseases. The "higher" the
scale of civilization the more insane are noted. Of course, this is
in part misleading because the care of the helpless that civilization

demands simply does not permit them to perish as they do under
natural conditions. Nevertheless there is no doubt that our kind
of civilization does favor the disease causing agencies, of alcohol
and and in America it was discovered that the negroes, who as
lues,
slaves had no percentage of insanity worth mentioning, become insane
in greater numbers the more they approach the manner of living
of the whites, and that in the northern states where thej^ are quite
acclimated they also attain the same morbidity. Furthermore, it
cannot very well be otherwise than that the elimination of natural
selection gradually increases the number of abnormals. As far as
the neuroses and obvious psychopathies are concerned, it goes with-
out saying, that under complicated living conditions, where a con-
science and feeling of responsibility exist and are continually needed,
they must more frequently let us say come to light than in carefree
and unconcerned people. That those who lead the parvenu life of
a metropolis commit race suicide in doing so, has been known for
a long time, but the path from the normal to extinction probably
traverses in part mental degeneration. Furthermore, just as in domesti-
cation of animals the artificial construction of human relationships
will produce all sorts of deviations from the normal. Though difii-
cult to evaluate, it an important circumstance that education is

is
now fraught with infinitely more dangers than in primitive times

CAUSES OF MENTAL DISEASES 2(J9
when the little ones did not soil the curtains and could not break the
statuary.
Naturally this is not the place to go into the details of the com-
plicated conditions of the artificial deterioration of race hygiene in
a big city; it is sufficient to know that insanity increases with the
density of population.
Great significance has always been ascribed to sexual conditions,
and it is not to be denied that at times a case of gonorrha-a in a
college boy who still has a sense of decency may release a depression
that must be designated as morbid. Diseases of the feminine genitals
are still more frequently blamed and for that reason operated upon
but without valid proof. The most severe blame is attached to onanism,
which is supposed to cause all neuroses and some of the more serious
mental diseases, and the patients themselves like to support this
view. But we see that it is carried on to an incredible high degree
by care-free insane patients and moral defectives without visible
harm'. Direct bodily injury can hardly be proven unless one wishes
to regard here the more or less painful feeling of weakness in the
back that suggests similar menstrual complaints and not seldom seems
to follow excesses. The real conditions are about as follows: Onanism
is an unnatural gratification of the most important instinctive impulse
of mankind which can be carried on very easily and consequently
leads not only to over-indulgence but would endanger the existence
of the race if there were no inhibitions against it. It is there-
fore comprehensible that our instincts are so ordered that our feeling
revolts against it. This feeling is supported by social and re-
ligious command and, perhaps, most strongly, even though in a harm-
ful way, by a literature that pictures for the adolescent in the most
horrible colors the consequences of the evil, in order to extort money
from him for cures. Thus where anxiety states and ideas of sin
appear, we usually also find accentuated ideas of self-accusations
concerning onanism which is thought at least, even if not always
expressed. Onanism then becomes the unpardonable sin, and we see,
moreover, that the fear of having harmed oneself becomes the cause
of many neurotic conditions, which can improve as soon as this fear
is removed." Naturally the useless struggle against the bad habit
and the resulting loss of self-respect result in very harmful factors.
However, onanism is often a symptom of disease, especially when
it is overdone or carried on in early childhood; or as a result of
schizophrenic shamelessness it becomes apparent not only because
^Bleuler: Der Sexualwiderstand. Jahrbueh f. Psvchoanalyt. Forschungen BA

V, 1913.
it is more frequent but also because it is practiced without fear before
others.
With a certain emphasis some nowadays also include sexual
abstinence among the causes of neuroses and even of mental diseases
but again without any proof. The daughters of certain classes,
catholic priests, as well as other chaste people, really offer sufficient
refutation; but it must be admitted that the general attitude has
become so frivolous that in many places, at least among the males,
almost only psychopaths remain chaste. If then many of these be-
come sick, it is surely wrong to blame their continence.
Among the sexual functions menstruation has a certain causal sig-
nificance for the psychoses. It rarely happens that the beginning
of maturity is marked by conditions similar to twilight or schizo-
phrenic states, which recur a few times at intervals corresponding
to the menstrual period but disappear with the regular setting in of
the menses, without leaving any psychopathic traces. Later the
menstrual moodiness which is not uncommon in "normal women" might
be heightened to a degree that may be designated as melancholic
depression; at all events suicides among women occur noticeably
often at this time. States of confusion also are said to occur with
or without impulsive acts. In addition the menstrual period can set
free fairly regular attacks of manic depressive insanity, while existing
psychoses are very often temporarily exacerbated at this time. But
it is a plain confusion of cause and effect, if the cessation of the
flow, so common at the beginning of an acute psychosis, is repre-
sented as the cause of the insanity. A "menstrual insanity" in any
definite sense has not been demonstrated in spite of different attempts.
The name puerperal (psychoses, those psychoses that appear during
delivery and up to about four or six weeks after it, are contrasted on
the one hand with pregnancy and lactation psychoses, and on the
other hand the term is used to designate all of the three forms. But
there are no special puerperal psychoses either in the wider or nar-
rower sense of the term. Nevertheless pregnancy in psychopathic
women, aside from the most different neurotic symptoms, may
obviously also condition melancholic depressions in both psychic and
somatic ways, or in both together. The delusions of such a psychosis
usually refer to the pregnancy and future of the child and disappear
after delivery without leaving any traces. It rarely causes the ex-
acerbation of a schizophrenia, otherwise it is probably a case of
chance coincidence of pregnancy and insanity. Cases of amentia
resulting from exhaustion, hemorrhage, or infection are said to appear
in child bed. According to my experience it is nearly always a case
of schizophrenia which becomes manifest or a schizophrenic exacerba-

tion, the release of which is to be explained mostly along psychic
lines. Even a manic depressive attack may sometimes be precipi-
tated by parturition. The lactation psychoses have little practical
significance.
At the time of the female climacterium a slight accumulation of
exacerbations of different psychoses shows itself; it also brings with
it a particular tendency to depressions. About a decade later we also
see in men mild but long lasting curable depressions that belong to
the period of involution (climacterium virile). Real climacteric
psychoses in women, which formerly were not uncommon, have dis-
appeared from the literature of the last few years.
For the remainder, the sexual life has much to do with the causa-
tion of mental diseases, especially of the psychoneuroses by way
of psychic influences; but we are far from being clear concerning
the degree and kind of its effects.^^
Among the other psychic causes an unsuitable education is cer-
tainly to be mentioned; as a matter of fact it is always being dis-
cussed although to be sure very little is known about it. We have
good reasons, however, for the assumption that many neuroses originate
through the aid of poor educational influences.
In later life it is only affective influences stirring the mind deeply
or for a long time that enter into consideration as causes of neuroses
and psychoses. To what extent care and sorrow produce real psycho-
ses is not yet known; no doubt the importance of their role is
exaggerated by the layman, whereas dissatisfaction, the feeling that

life has been a failure and, above all, erotic difficulties (in the wider
sense) causes flare-ups of neuroses and exacerbations of the psychoses.
In psychopathic persons terror, anger, or despair can produce excite-
ments of blind rage with subsequent amnesia or stuporous states
(emotional psychoses, anxiety deliria) which quickly pass away.
,
Imprisonment precipitates different psychopathic conditions, also such

resembling paranoia; it is also said that operations produce mental
diseases. This is undoubtedly very rare.
Modern accident laius arouse imaginative desires and have con-
sequently become the most important causes of traumatic neuroses
in the wider sense. Other transient mental and nervous disturbances
originate in great catastrophes, as in earthquakes.^^
The public often fears infection from the insane. It does not
"Concerning the Freudian viewpoint Cf. some observations in the chapter

on neuroses.
" Cf Fright neuroses.
.
exist in this form. On the other hand energetic patients can impart
their mania to the apparently healthy who live with them {induced
insanity). To be sure, occasionally even the entirely healthy are
dragged along by insane litigants or reformers. Thus from induced
insanity there are all the intermediate stages to psychic and nervous
epidemics, such as chorea major, tic epidemics in schools, and re-
ligious epidemics, that certainly' may attack even well balanced
natures.
Childhood disposes to brain diseases, and above all to polioen-
cephalitis. "Child (psychoses" sui generis are not known, unless one
so designates oligophrenias which are to be attributed to diseases of
infancy, paresis which comes from hereditary syphilis, and the epilepsies
that break out at this age. Schizophrenia also, and more rarely
manic depressive insanity, at times begin in early childhood. Deliria
in childhood are comparatively frequent in cases of intoxication
and infection; occasionally they show at these times catatonic symp-
toms, (e.g. catalepsy), which have no deleterious significance under
these circumstances. Hysterias in childhood are frequently mono-
symptomatic and have less the character of a psychic general disease
than those of adults.
The disposition to mental disease increases explosively with
puberty; and where neither alcoholism nor paresis constitutes an
essential part of the disease, the disposition decreases slowly from
the twenty-fifth year and quickly between thirty-five and forty.
A "puberty psychosis" peculiar to the period of development is not
yet known, unless the above mentioned coincidences previous to the
inception of menstruation are to be called so. What used to be so
designated were usually schizophrenias.
During manhood the alcoholics, paretics and paranoiacs become
manifest, then, also the traumatic cases from comprehensible external
causes.
The period of involution brings with it a small increase of schizo-
phrenic conditions, a more considerable increase of depressions, and
then a number of less common diseases, some of which were described
by Kraepelin. But the period of involution is to be sharply differ-
entiated in this respect, as well as in general, from senile degenera-
tion, even if the two processes may touch each other. Like puberty,
it is a re-formation for another stage of life; the normal matron for
more than two decades is still a capable person.
on the contrary, is a reiro-formation, a dying out. If

Senility,
the retro- formation of the brain precedes the retro-formation of the
other organs, it shows itself clinically in the pure form of dementia
senilis. Moreover, arteriosclerosis and presbyophrenia, while not en-

most commonly met with it.
tirely peculiar to senility, are still
The male sex is disposed more than the female to idiocy and
epilepsy, and less to neuroses and manic depressive insanity. If
alcoholism and paresis primarily affect men, this is due to their

manner of living; that they prefer this manner of living, is again
based on sex. On the whole more men are taken into the insane
asylum; but their numbers are generally less than those of women, be-
cause the alcoholics are usually quickly discharged and the paretics
die. Among the older insane patients there are more women because
of the greater longevity of the sex.
CHAPTER XI
THE TREATMENT OF MENTAL DISEASES
IN GENERAL
The treatment will here only be considered as far as it concerns

the requirements of the practicing physician and as far as its dis-
cussion, independent of clinical demonstration, may be of some use.
Concerning the neuroses reference must be made to textbooks on
neurology}
As yet very little is done for prophylaxis, and without a change
of the general attitude and legislation very little can be done. The
more severely burdened should not propagate themselves. Some
have recommended "social sterilization"; others have challenged ''the
infringement upon human rights" and found it useless. Many dis-
eased and degenerates are themselves quite willing to undergo the
operation, and though the opportunity may not be very frequent,
it may be of use in individual cases. Moreover the idea is capable
of expansion, and that is just what is feared. Ido not fear it: because
as long as the now current attitude is not completely changed, the
danger of overdoing exists almost only in so far as the practice would
get ahead of the development of the ideas and consequently might
for a long time discredit these measures. I would begin with compul-
sion in the case of incurable criminals and on the basis of consent in
the case of other more serious psychopathies, and then gradually alter
the general attitude and legislation in accordance with experience.
But if we do nothing but make mental and physical cripples capable
of propagating themselves, and the healthy stocks have to limit
the number of their children because so much has to be done for
the maintenance of the others, if natural selection is generally sup-
pressed, then unless we will get new measures our race must rapidly
deteriorate.
Also the deleterious influences that act on the germ, among which
I class the living conditions in large cities, should be seriously attacked.
To quote Kraepelin: "It must also be the sacred duty of physicians
Comp. especially the chapter on Psychotherapy by Mohr in Lewandowsky,
^
Handbuch der Neurologie, Julius Springer, Berlin. And Schultz, Die Seelische
Krankenbehandlung (Psychotherapie). Fischer, Jena 1920.
214
THE TREATMENT OF MENTAL DISEASES IX GENERAL 215
to increase gradually the pressure of public opinion in such a way

that the resolution will be formed to take up the battle against alcohol
and syphilis with thesame emphasis and the same resort to remedies
as in the battle against tuberculosis." All "Back to nature" move-
ments also are to be supported much more energetically than here-
tofore, but not to the bogey that is called nature. Even in our in-
dustrial age the race sustaining power of agriculture could be utilized
for prophylactic measures.
A purposeful bringing up might perhaps prevent many a neurosis.
We nervousness and morbid characteristics grow directly
see, at least,
from an inadequate training and must therefore conclude that proper
influences with training of the will and particularly of the character
to become habituated to tolerate the disagreeable, including pain, and
hardened within sensible limits all that could preserve from sickness
many who are not too severely burdened. A careful selection of
vocation will also furnish a certain protection. It is also conceivable
that the timely solution of inner conflicts in the milder schizophrenic
process could postpone the breaking out of secondary symptoms, i.e.
of the manifest insanity.

In pronounced disease the chronic cases should be differentiated
from the acute. The chronic cases, for the great part, are to be
trained to normal conduct and work; but since besides physicians
few people understand such a training, its direction is still the task
for medical men. The layman, even when he is ever so well mean-
ing and intelligent, still forgets too easily the difference between sick
and well, and thinks he can work with logic and indignation and
kindliness, as is properly the case with the healthy. But just in those
things that matter, the sick frequently have a false logic and still
less do they understand indignation at their acts, which they con-
sider proper. Or can gratitude be expected when they do not at all
value our sacrifice or only negatively, i.e., when they take them as
chicaneries? Here it is a question of carefully ascertaining the
patient's general modes of reaction and especially those toward par-
ticular individuals, and then act as seems best in the particular situa-
tion, and not from a sense of justice, or anger, or sentimental sympathy.
An indispensable means of training is icork, which also renders
incalcuable services against many symptoms. Whoever considers him-
self too good for this or whatever kind of work he could still accom-
plish is not good enough for it. But also in the beginning of mental
diseases, especially of schizophrenias, one should not permit work to
be dropped at once without some definite reason. When
adapted to
the ability of the patient, it usually does more good than so-called
rest and recuperation, and this is particularly the case in many light
melancholias such as the physician will most probably have to treat in
his private practice. Mental work, also, is not to be excluded on
principle, even though it is frequently not applicable, more because
of practical than inner reasons. But the worst is "the poison of
laziness" (Rieger).
Milder chronic cases can be sent with very good results to a
Psychiatric clinic where the patientis braced up from time to time^
where he receives the necessary remedies, and where a special effort

is made to make the external conditions bearable.
In acute diseases the object of obtaining a cure is of uppermost
consideration, but unfortunately we cannot do as much as we should
like. In individual cases special psychiatry has to lay down the
necessary rules.
An important question is "Which patients are to be committed to a
hospital for the insane?" Naturally, all those who cannot be kept out-
side because they are too dangerous to themselves, to others, or too
disturbing. Some can be properly treated only in an institution be-
cause they themselves or sometimes their relatives oppose a proper
management of the case. Where the danger to the patient's fortune is
the chief indication, a legal guardianship can at times take the place of
an institution or shorten the stay. Not seldom patients must be in-
terned, not because their conditions directly require itj but because
their relatives are worn out by taking care of them. It is also
not unusual that the family exerts a directly harmful influence on
the patient, hence the indication for institutional care lies in the
existing conditions.
To intern an insane patient compliance with a number of formalities
is necessary, which unfortunately vary in different states. Every
physician who settles down to practice should injorm himself about
these local formalities; if he waits until the occasion arises he is
apt to encounter many difficulties. In almost every state a physician's

certificate is required. In the state of New York it is a legal act and
must therefore be carefully filled out with the required data. Be-
sides the petition to the court, signed if possible by the nearest rela-
tive, it must also contain a physician's certificate signed by two
qualified examiners in lunacy who must examine the patient conjointly
within five days of the presentation of the petition. Such a certificate
must contain information about the patient's legal standing whether
he is charged with a criminal act or not, his financial standing
whether he has relatives who are able to pay for his maintenance in
the hospital (if not committed to a private institution) and the
THE TREATMENT OF MENTAL DISEASES IN GENERAL 217
physical and mental states of the patient, whether he is dangerous
to himself and whether he shows hallucinations, delusions,

others,
depression, exaltation or other abnormal signs. It is often not possible
to make a definite diagnosis after one examination but for pur-
poses of commitment this is not essential. It is merely a question
whether the patient is insane and unmanageable at home. The neces-
sity for institutional care must in every case be specified. (Is the
patient dangerous to the community, does he refuse nourishment, has
he suicidal tendencies, etc.?)
Without the legal commitment no insane patient will be admitted
to a state institution, so that it is advisable to inquire first of the
hospital superintendent whether the patient can be received. Not all
hospitals are in position to receive patients at all times.^

So much for the administrative details. In addition the physician
at the institution should receive all the data required for the treat-
ment of the patient, his outward behavior, presence or absence of
particular inclinations or impulses, so that a harmless patient does
not have to be sent at once to the observation ward. He should
also obtain the anamnesis, information concerning the patient's past
treatment and its success; whether the patient was given narcotics
on the trip to the hospital, which kind, and in what doses? Hyoscine
can give the appearance of a pupillary disturbance and lead to a
wrong diagnosis. It is best not to give narcotics on the first day if
one does not know whether the patient has already been given the
same. Sometimes the physician has no time to ascertain all this and
make a note of it. Then he sends with the patient a preliminar}-
certificate with the necessary data and states that the detailed re-
port will be sent on the following day.
Moreover the hospital physician will be grateful to get not only
the practically necessary information but also that which may be sci-
entifically interesting.
In bringing a patient to an institution one should not resort to lies
and false pretenses; that would make a beneficial treatment impossible
and especially in the case of patients who have some self-respect, it
would permanently disturb the entire relationship with their rela-
tives. In an emergency it is better to use force or a hypnotic, which
is more readily forgiven by the patient. But force is ver^* rarely
necessary when the proper procedure has been followed. A large
part of the patients can be persuaded, if, without losing one's own
'This is not necessary in most of our big cities where psychopathic hospitals
or pavilions are maintained for obsei-vation, treatment and commitment when
necessary.
self-possession, one explains the decision for a hospital on grounds of
necessity; but it must be told so decisively that they feel that any
discussion whatsoever is useless, and that there are enough people
present who would be capable of putting the thing in operation in the
face of resistance. It should not be forgotten that it is only in the
rarest case that logic itself makes the patient yield; it is the personality
of the individual who applies the logic.
When the patient is in a hospital, the family physician fre-
quently has to continue his function as advisor of the family. The

questions about private or public institutions, about visiting the patient
and taking him home must all be advised by him. In this matter
it is difficult to give general rules. One must guard against giving
advice without knowing exactly the actual state of the case. It
is best to get in touch with the hospital physician; moreover, in such
cases professional courtesy is of greater value to the patient and. his
family than to the professional relationship. At all events the physi-
cian should know that manic depressive patients are frequently taken
out too soon, and schizophrenics very rarely, unless other considerations
than the patient's condition come into account. Only in exceptional
cases is home-sickness an indication for taking the patient home;
usually what the patient and relatives take as such is not home-sick-
ness at all. The patient does not feel at ease anywhere and then
the cause is sought in the separation from home. Patients who are
cured hardly ever urge to be sent home. The dreaded "living with
other markedly insane patients" is sometimes an unpleasant experi-
ence but it is not a hindrance to the cure. It is very harmful if
visiting relatives give the patient hopes of coming home or of any-
thing else that cannot be fulfilled later. Moreover, visits are some-
times harmful; they frequently disturb an acute patient, especially
in the beginning when he has to get used, to the institution, I should
like to call attention to the younger children who almost without
exception overcome home-sickness after a few days, but on condition
that they are not visited. But even in the case of chronic patients
visits interfere with the adjustment to the new home even where they
are carefully and tactfully carried out.
The selection of an institution is frequentty not easy. Where
overcrowding has not become excessive, public institutions are gen-
erally the ones that accomplish most for the least money. This is
naturally counterbalanced by the fact that there is frequently less
comfort and less consideration for the wishes and moods of the in-
dividual. The latter may also he an advantage. All private sana-
toria are far from being well equipped for restless patients. Sometimes
because of the "odium," or from false pride relatives want to avoid

public institutions and sacrifice money to this idea that would be
better applied in other ways, e.g. during the period of recuperation.^
But it is self-evident that good private institutions can offer much,
especially to spoiled patients, that they are deprived of in a public
institution. But it is more difficult to carry out a rigid training there
than under the inexorable rules of a general institution (care should
be taken especially in deprivation cures, see morphinism).
Some patients, e.g. oligophrenics and cases of schizophrenia that
have run their course, can often be trained with success or also
kept for a long time in a private family, with a doctor, teacher, or
minister. In some places private family care is publicly organized
also for the poorer classes and has proved to be very successful. The
guardians are preferably farmers or former nurses and attendants
from hospitals.
The disease itself can only be attacked directly in a few cases such
as cerebral lues and epilepsy. On the basis of chance experience with
dementia prsecox, an artificial fever has been produced by the injec-
tion of bacterial toxins {Wagner von Jauregg). The toxins, how-
ever, can be advantageously replaced by somnifen. Tertian plasmodia
seem to neutralize the spirochites in paresis.
In despair the family often assumes expensive treatments in cases
of incurable patients that set the family back financially and thereby
make a later proper treatment of the patients impossible. This is a
grave wrong. It should not be forgotten that curable cases are
usually cured for the m.ost part by time.
Against emotional fluctuations, distraction sometimes has an effect
only in milder cases. To argue with the patient about his delusions
is nearly always useless or harmful. One should not conceal his
own viewpoint from the patient but at the most, it should be left to
the future to prove who is right.

With the exception of the psychoneuroses, mental diseases offer
'Such an odium especially entertained in reference to our State Hospitals,

is
thus furnishing no problem for the consulting psychiatrist. It is easy
little
enough to dispose of the wealthy patients, thej' are invariably sent to private
sanatoriums, and of the greater part of the poor, who go to state institutions,
but one often at his wits' end to know what to do with middle class patients
is
who cannot afford a first class sanatorium and would under no circumstances
go to a State Hospital. I have known families who actualh- became ruined
financially in their zeal of maintaining a praecox in a third rate private sana-
torium. The State Hospital could have offered them just as good, in my

opinion much better service, but owing to the mediaeval prejudices which our
newspapers continually change into modern garb, the average person is still
horrified when a public institution is suggested. (Editor.)
no fertile for psychotherapy in the narrower sense.*
field Manic
depressives, and similar cases recover from the attack, organic cases
perish, while schizophrenics live on uncured. But just in the case
of the latter it is of especial importance, whether one understands
them, and can think oneself into their condition, only an extensive
occupation with psychopatholog^-, delusional and symptomatic forma-
tions, blockings and inhibitions, can assist in this. Suggestion, whether
direct or concealed, will always be carried on, just as in medical
practice and in life generally. In some cases hypnosis may make many
things easier, e.g. in residual conditions like insomnia following mel-
ancholia. On the whole, its significance in real psychoses ^ is not great,
because as Forel expressed it, in hypnosis one works with the patient's
brain, which in the case of mental diseases is an ineflBcient instrument.
One most important psychical means of therapy is patience,
of the
calm, and inner good will for the patient, three things that must be
absolutely inexhaustible.
From definite "procedures" in the case of psychoses in the narrower
sense, very little is to be expected even though milder cases at times
are favorably influenced in hydrotherapeutic institutions where one
exercises care. A careless application of cold water may do decided
harm. On the other hand baths of normal or near normal bodily
temperature are an important help in the treatment of restless and
sometimes also of depressed patients. Excitements are often reduced
by a bath a feeling of tiredness without a real reduction of psychical
;
and physical capacities makes the patient more accessible. But even
in those cases where this result is not visible the tepid bath (35 to
36 C.) is an excellent resort for the patients who can constantly
occupy themselves with the water and thus remain harmless to them-
selves, to others and to the objects about them. The introduction
of the continuous baths, used also in some institutions throughout
the night, and the use of wards for sleepless patients, has given the
modern insane asylum a much better appearance. The depressed
patients also are frequentty better off in the bath; a warm bath,
taken at night, is especially conducive to sleep.
Cold packs are also frequently applied, and the patient is kept
in them for about twenty minutes until he gets warm or even for
many hours. The latter is only resorted to in the case of good con-
*
That psychotherap}^ according to definite methods, such as that of Freud,
is,
Dubois, hypnotism, etc. It is self-evident that "psychotherapy" in a wider

sense is practiced by ever>' psychiatrist, I should almost like to saj^ not as such.
"
In contradistinction with the neuroses. Even those who are not very skilled
in hypnosis will find that such cases as monosymptomatic hysteria or enuresis
are frequently readily susceptible of this treatment.
trol of temperature, appearance, and psychical condition. Occasionally

they also have a soothing effect. But if the arms are not wrapped
up, they are not tolerated for long, ju^t by those patients; who need
packs most; and if they are put under the blanket this procedure, ac-
cording to my way of thinking and that of my patients, becomes, under
the guise of medicine, the worst means of restraint that exists. I
therefore avoid packs as much as possible.

Very many patients, especially the depressed, also schizophrenics
who do not occupy themselves, and mild manics are best off in bed;
if they want to occupy themselves, there is no objection to reading,
writing, and feminine handwork. Every modern institution has a

number of wards where the patients remain in bed day and night under
constant surveillance, but there must be a definite indication for
this; one should not merely feel that "patients should be in bed."
In chronic cases work is to be preferred if it is possible.
If patients are very excited or annoy and injure others, they are
under eertain circumstances isolated. Nowadays there are physicians,
and there were even more ten or twenty years ago, who regard isola-
tion as an atrocity. With discrimination, properly applied, I consider
it a blessing for all concerned. In the case of manics who do not
necessarily soil everything it is the preferred therapy. And at night
probably every healthy person would prefer to be alone in a room,
even if it is called a cell, rather than in the company of many lunatics.
Other means of restraint are to be applied most rarely; but when
there is a special indication, as in the treatment of a fracture, I con-
sider it wrong to let the patient become a cripple because of considera-
tion of principle.
Where artificial feeding is necessary, the patient can only rarely
be kept in a private house. A well nourished person, if he remains in
bed, can go without food from five to seven days without harmful
effects,unless he has previously put himself on half rations. One
should not bother with rectal feeding and similar emergency measures.
On the other hand there are sometimes roundabout ways by which
nourishment may be given the patient; thus some will eat secretly,
if food is left within their reach as if by accident. If tube feeding
is necessary, it is best done through the nose. The patient is held
in a reclining or sitting position firmly enough to preclude a struggle
during the process. Then a well lubricated soft tube is inserted into
the wider nostril, so thick that it just goes through. The bending
at the posterior wall of the throat is forced by a little push. From
here on the insertion should be made somewhat quickly, so that the
patient has not time to guide the tube into the mouth.
In any case, it is often well to wait for the pharyngeal reflex
and as soon as it begins, to shove the tube into the oesophagus. It
is then inserted into the stomach, and through the auscultation of a
little air, blown in by balloon or mouth, one makes sure of the cor-
rect position of the tube. Lack of reaction by the patient, especially

in the case of catatonics, is no guarantee that the tube is not in the
trachea. When the tube is withdrawn the tube should be pinched shut
so that nothing flows into the larynx. The simplest thing to inject
is milk and half as many eggs as a deciliter of milk. After a pro-
longed fast one may pour in five deciliters at the most the first time,
later one liter of milk and five eggs at a time. Two daily feedings
will then usually suffice. The state of nourishment, digestion, vomiting,
are naturally always to be watched carefully. Medicines may also
be mixed with the food and in case of a longer period of illness a
different food, in fluid or semifluid condition, will probably be given
in place of, or in addition to, milk.
If the patient causes special trouble, he should be committed to an
institution. In case of narrow nostrils the insertion of the tube
through the mouth may sometimes become necessary, also to wash
out the stomach after poisoning. In the case of patients who offer
resistance one must use a gag and be sure to protect one's fingers;
then insert tenderly but without fussiness the left index and middle
fingers until reaching the back of the epiglottis which is pressed for-
ward a little.Guide the tube between the two fingers directly to the
entrance of the oesophagus, which can only be forced in this way
by a soft tube against the patient's will.
Electricity, massage, climatic influences cannot be used as yet.
Nor can hardly anything be gained by a definite manner of nourish-
ment; special additional indications naturally excepted (compare also
therapy of epilepsy). On the other hand strong nerve stimulants such
as coffee and tea should be avoided, and above all alcohol has so many
disadvantages that the little benefit which here and there is sometimes
claimed for it does not enter into consideration.
Hypnotics can never be dispensed with entirely; in institutions
they must often be given because of the other patients whom an ex-
cited patient keeps awake. Certainly the less one uses, the better;
but if one is careful, that is, if one never gives it daily for any length
of time and changes the drugs, one will not have any unpleasant ex-
periences. To be sure one must watch the urine for the effect on
the blood when administering Sulfonal and Trional. Chloral Hydrate
is still one of the best drugs when given in doses of 2-3 Gm. (Blood
pressure!) and eventually in smaller doses together with mor-

phine. Of the newer drugs Veronal (0.5 to L5; eare nephritis!)

and Veronal of Soda (0.5 to LOj are particularly useful. The latter
may also be given in enemas. Trional and Sulfonal are also given;
the former acts quickly but not continuously, the latter slowly but
effectively and very readily shows a cumulative effect. Hence LO
Trional can sometimes be combined with 2.0 Sulfonal to obtain an im-
mediate and, at the same time, a more lasting effect. In the case
of excitations of not too long duration a certain calming effect can
be attained with Sulfonal, if it is frequently given (the cumulative
effects manifest themselves by disturbances of coordination). The
specified doses, with the exception of those of Sulfonal and Trional,
may be exceeded without danger with patients whose reaction is known.
In real excitations energetic doses should be administered or none
at all; one should be glad if anything at all produces results. Paralde-
hyde (5.0 per dose and more, always through the mouth) would be
one of the best hypnotics if it did not have such a bad taste and odor.
In single doses it is entirely harmless, but it cannot be given for a
long period. Amylene hydrate (2.0 to 5.0) is well adapted for rectal
administration and is sometimes successfully used especially in status
epilepticus; but it must be well diluted with starch or something similar
when given as an enema, otherwise it attacks the mucous membrane of
the intestines.
Many recommend alcohol as a hypnotic. It is the pleasantest, but
as it may become a habit it is the most dangerous and least effective.
I do not think it worthy of physicians to prescribe a drug which is

most pleasant but most dangerous and ineffective.^
In nervous excitements resulting from fatiguing W'Ork bromide in
smaller doses is excellent (1 to 3 grammes to be taken evenings all
at once, or perhaps still better in two doses, but it must be thoroughly
diluted). In milder depressions it is more rarely effective, in severer
ones not at all (comp. Melancholia).

Opium and opiates are not hypnotics. But indirectly by removing
fear and psychic pain they can have a calming or even hypnotic effect.
In psychoses, however, they do not achieve by far what their effects
on the healthy would lead one to expect. With the exception of a few
cases, their use can be dispensed with, and because the danger of
habituation to opiates is very great, especially with psychopaths,
there is good reason to avoid them as much as possible. To give opiates
If supposedly necessary for any other reason to prescribe alcohol as a

it is
medicine, should be prescribed like any other remedy in definite doses and
it

for self-evident reasons without the patient knowing it, as: Spir. Vin. 30.0.
Aqua 130.0, Syr. Liquir. 40.0.
to an excited patient to facilitate the transfer to an institution is
hardly ever of any use but it constantly occurs nevertheless.

Hyoscine (Scopolamin, Euscopol) hypodermatically in doses of
0.8 to 1 mg. (above the maximum dose!) is best in such cases; if the
patient's reaction is known and the drug is fresh, more may be given,
up to 1.5 mg. It has a decidedly better effect in combination with

morphine ten times the dose of hyoscine and in frequent use this
addition overcomes the harmful influence of hyoscine on the digestion.
If one gives smaller doses of hyoscine (about 0.3 mg.) as some recom-
mend, one can add more morphine, e.g. 0.015 g. per dose. Within
more recent times somnijen has been used both as a hypnotic and
sedative (40-50 minims internally; some give bigger doses). The
more exact medications are still to be determined.^
Among particular symptoms which the practicing physician has to
deal with, undeanliness should be mentioned. Many mechanical ar-
rangements have been constructed, particularly for the unclean bed
cases, and all have been given up. The best thing is immediate clean-
ing, day and night, after every evacuation. In many patients, es-
pecially those not paralyzed, smearing of feces can be done away
with, if every evening, if possible at exactly the same time, they are
given an enema and urged to move their bowels.
Formerly it was thought necessary to do much to prevent masturba-
tion.^ This struggle, which is not only useless but which also keeps
the attention of the inmates of the institution directed to the evil, I
gave up long ago and am glad of it. But at all events care must
be taken that onanistic acts are not carried on openly and do not
anger the others or infect them. In cases where the patients them-
selves are struggling against the impulse, medium doses of bromide
(2.0 to 4.2 per day) are sometimes effective. Epiglandol, which to be
sure is better, can also diminish the impulse.
For a treatment of the danger of suicide see manic-depressive

insanity.
If operations on the iiisane are to be undertaken, unless it is a
question of life and death which makes immediate action necessary,
one should obtain the consent of the relatives or of the guardian,
perhaps of a counsel named for the purpose. The practice in this
case is pretty well free from trouble; the theoretical difficulties, how-
ever, are numerous; there are foolish people who do not wish to de-
prive a person incapable of action of "the disposition of his own
body" and would rather deprive him of life or limb than amputate
^ See also Treatment of Schizophrenia.
' Comp. p. 209.
a couple of gangrenous toes against his will. The reduction of a dis-

location, the proper treatment of a fracture naturally do not belong
to the "operations" in the specified sense; this is not true, however, of
lumbar punctures which require considerable skill. Every beginner
does well in these matters to ascertain exactly the customs or require-
ments valid in his district.
The interruption of pregnancy ^ requires special indications. In
depressions of pregnancy ^" the intervention frequently only causes
the patients severe reproach and the condition is aggravated, while
by mere waiting with sufficient oversight the psychosis is regularly
cured, not seldom even before the delivery. However, the psychogenic
depressions or situation melancholias of girls and women for whom
the child will make difficulties are theoretically to be judged differently.
Such diseases can naturally be cured by the removal of the cause;
but with our present views and laws this cannot be a sufficient in-
dication for abortion. Even in the case of schizophrenia and oligo-
phrenia in spite of all may be advanced, the
the valid reasons that
sacrifice of the child is only decided on in exceptional cases. It is
quite different in the case of early and severe eclamptic or choreatic
psychoses. In Germany and in Catholic districts, according to the
weight of opinion, a special indication (danger of a diseased progeny
in the case of the insane and idiots; reaction of nursing difficulties
on the condition of the mother) does not properly exist. In the
Protestant part of Switzerland the sensibilities of the people demand
an attitude that is more favorable to abortion and I should let social
considerations count with the legal. Plain legal determinations exist

nowhere; one has to fall back on local and customary interpretations.
At all events, it is wise not only to weigh carefully all the circum-
stances that enter into consideration, but to consult an experienced
colleague. Psychiatric indications of premature birth are more rare
and simpler.
^ Comp. E.
Meyer, Klinstliche Unterbrechiing der Schwangerschaft bei Ps>'-
chosen (mit Einschluss der Hysterie und Neurasthenie). Med. Klinik 191SL
No. 7 u. 8.
" Cf. pp. 210-211.
CHAPTER Xn
THE SIGNIFICANCE OF PSYCHIATRY
The frequenc}' of psychical diseases is fairly great. Some are of
the opinion that about two per thousand of the population is pro-
nouncedly insane; but this does not include those "who were insane,"
the mental defectives, who are more than again as numerous as the
manifestly insane, and most epileptics. And it is not to be doubted
that the facts exceed by far the estimate. The most exact enumera-
tions give about one percent of the population as insane and oligo-
phrenics. From an investigation of conscripts Maier goes so far as
to raise it to twô percent. In its insane asylums alone Germany
has to care for more than one hundred thousand insane. According
to statistics obtained by the National Committee for Mental Hygiene
there are about two hundred and fifty thousand patients in the hos-
pitals for the insane in the United States. New York State supports
about forty-three thousand patients in its State Hospitals.
But the estimated pecuniary loss to the individual is not less than
the loss to the people generally. The paretic who has made a position
for himself and has a family and then permits both to go to pieces
is a frequent occurrence, the same is seen in the case of the hebe-
phrenic, who maintained at the expense
for a half century has to be
of the family and the state and who retards the former economically.
Added to this, is the peculiar significance of insanity. The psyche
is the essential element in man, not only from a religious but also
from the viewpoint of natural science. Strong muscles and solid bones
are still agreeable attributes for those who have them, but one can
direct a world without even having arms and legs, while a slight
disturbance in the psychic mechanism can change the strongest man
into a pitiable object of care or into a dangerous enemy of society.
It is importance
for this reason that the psychoses attain their social
much more than other diseases; they spread their harm to wider
circles and they rob the patient himself of his independence in alf
his relations to his fellow men. They falsify or destroy his social posi-
tion. He can no longer maintain himself, and he loses his qualifica-
tions as a legal subject. What was said applies only to the recognized
insane, but if the insane person is not recognized, the consequences
226
THE SIGNIFICANCE OF PSYCHIATRY 227
are often more serious for him, above all for the family, and some-
times for society. In many cases unbearable conditions improve as
soon as the diagnosis is made.
Hence the great and sometimes dreaded import of psychiatric ex-
pert opinion.
And the significance of psychological and psychopathological con-
siderations is always becoming greater. The penal code whose old
standards are no longer adequate for modern viewpoints and con-
about to forge new weapons for itself in the battle against
ditions, is
the enemies of society. This can only be accomplished with success
if the conclusions drawn about criminals are based on studies and
application of psychiatric methods of investigation and psychiatric
prognostication. In civil jurisprudence psychical conditions are ever
becoming more important; the psychological problems, which the anti-
quated insanity code presents to the judge and the expert, are already
so large and so numerous that the profession will have trouble to
meet them. A jurisprudence without a thorough psychological training
is becoming more and more insufficient.
The same is true in other sciences. Our ethical instincts are no

longer equal to the modern conditions of life and like the other instincts
become inadequate with a progressive civilization; indeed, under
certain conditions they even become harmful, (e.g. the instinct of
revenge). Religions which since Buddha have regarded ethics as
their domain, no longer have the general influence that they had in the
last two thousand years. A conscious ethics can naturally spring only
from the intimate study of the social psychology of man.
History is at last beginning to become psychological and conse-
quently a comprehending science, because it is the product of the
human psyche.
Pedagogy is getting ready to derive benefit from a penetrating study
of the soul of the child.
In the last half century our literature has become immeasurably
more psychological, even though in this respect it has not yet caught
up with the French and Russian. Poetic compositions and especially
their creators, themselves, can only be properly understood by an
extensive psychological study.
A particularly fertile field scientificalty and practically is the
borderland between the normal and disease. The normal and average
man is the product of adaptation to conditions and must consequently
always hobble along somewhat behind the requirements. He dare

not conspicuously develop a single characteristic at the expense of
others, because he is above all the physical forebear of the future
generations and as such must be able to bequeath in proper propor-
tion all psychical gifts needed by society. But civilization is fur-
thered by those who are developed in a one-sided manner, who in-
wardly and outwardly specialize themselves, who carry out the division
of labor, and by those who are not sufficiently adapted to be satisfied
with everything that exists.

But while the lines of deviation are countless, the useful pos-
sibilities are naturally few. Thus the bad prophets, the clumsy world
reformers, the fanatic partisans who are inspired by all sorts of
unrealizable dreams, and those who are really regarded as sick are
and will continue to be the majority of the abnormal. To recognize
them in the morbidity of their inner life is a problem that is prac-
tically important, that could contribute materially to the improvement
of our public affairs.
The study of race and mass psychology, which is dominated by
such people, should complete this knowledge. Psychopaths and in-
sane, such as Mohammed, Luther, Loyola, Rousseau, Pestalozzi,
Napoleon, and Robert Meyer, have influenced the course of our civ-
ilization in a fateful or beneficent way. The psychic epidemics from
the crusades and the dances of St. Vitus to the twitchings of modern
school children, and the numerous sectarian and party movements in
religion, politics, and art, all represent the readily discernible peaks
of the fluctuations of ideas, in which the psychic life of races expresses
itself and from which the achievements of individual leading spirits
grow as advanced pathfinders, as complements or as negatives to the

general current.
For the physician a psychological training is nowadays particularly
necessary. While the naive practice of medicine was always in great
part psychic, and the quack even yet partly heals and partly shears
his patients by following psychic lines, the development of the exact
methods of modern times has diverted the physician from psychical
conceptions; indeed, as Adolph Meyer expresses it it has engendered
an actual "Psychophobia." But theory and practice are suffering
severely from this, when one side of a man is neglected and to be
sure it is the one which through ideas and affects is the chief regu-
lator of all bodily functions, and which alone decides the relation
between physician and patient. The good practitioner is still pre-
ponderately the good, though usually instinctive, psychologist. The
origin and disappearance of "Neuroses" goes by way of the psyche.
The control of diseases of accidental origin, which cost the exchequer
millions, and which make permanent cripples of many people, is only
possible since their psychic origin has been grasped, and the mani-
THE SIGNIFICANCE OF PSYCHIATRY 229
festations of a good many other diseases in the single individual are

modified and modifiable by the psyche. The usual digestive and
menstrual difficulties are in large part entirely psychogenic diseases.
Mental hygiene in the family is not less necessary to the happiness of
mankind than physical hygiene; in short, a complete physician must
understand the complete individual.
Now experience has shown here as everywhere, that it is difficult,
yes, impossible to obtain insight, if only the commonplace, the normal
is considered. That accounts for the fact that psychology in the past
could not only not contribute anything to all these purposes, but was
positively a hindrance to better insight. Only the newer schools such

as those of Marbe and Stern tend in this direction. Hence what is
important we shall only recognize from the study of the growing
psyche of the child and, above all, from the aberrations of those
already developed in psychopathology. At this time one of the most
important, if not the most important path to a knowledge of the human
soul is by way of psychopathology.
CHAPTER Xm
THE INDIVIDUAL MENTAL DISEASES
LV. THE ACQUIRED PSYCHOSES WITH COARSE BRAIN

DISTURBANCES. THE ORGANIC SYNDROME
Kraepelin has here differentiated injuries and diseases of the brain
and for practical reasons syphilitic diseases are separated from the
latter. Among the syphilitic conditions again the most important,
paresis, has been emphasized because of symptomatic, and
its historic,
practical individuality. With the senile forms and the real Korsakoff
disease resulting from intoxication (alcohol, CO, lead, bacteria toxins,
etc.), it has in common the diffuse reduction of the brain and with
this, a large part of the symptomatology. These three forms are
thought of first when the organic psychoses are mentioned. But they
include also the various forms of degenerations of the nervous system,
such as the glioses, multiple sclerosis, cerebral changes in tabes, tumors,
etc. They alone have in common the "organic syndrome," which with
a one-sided emphasis of the memory defect was also designated as the
Korsakoff symptom complex} Naturally it can also be found in
other brain diseases, as soon as they result in a diffuse cortical lesion.
If the cortex as a whole is only functionally damaged by a trauma,

these symptoms may again disappear "curable Korsakoff" the same
is true in an intoxication with adjustable anatomic disturbances
(delirium tremens).
Only weakening of
diffuse disturl)ances of the cortex cause a real
intelligence,whereas certain affective disturbances can already mani-
fest themselves in cortical brain lesions, most frequently when it
affects the thalamic region. Irritability and a tendency to all sorts of
temporary moodiness, again in the direction of anger and rage, are
the most common persistent manifestations in most focal lesions of
the brain, but in diffuse disturbances as well as in lesions in the
thalamic region, the general affective lability would seem to be more
marked.
^Korsakoff's disease is really a toxic neuritis of the peripheral and central
nervous system. The name was then incorrectly transferred to other diseases
showing similar memory disturbances.
230

THE INDIVIDUAL MENTAL DISEASES 231
THE ORGANIC SYNDROME

The diffuse reduction of the functions of the cortex results in definite
symptoms, which only vary in detail according to the circumstances
and the diseases.
Memory: - All things being equal, the fresher an engram, the
worse is recollection ranging up to complete absence of impressibility,
the older it is, the less the memory is disturbed. who evince
Patients
a greater poverty of thoughts often fill their memory gaps with
(real) despairing confabulations, while the more productive ones,
going beyond this, revel in spontaneous pseudo-recollections. Transi-
tory confusions or other disturbances of consciousness (attacks of all
kinds) are frequently followed by amnesias.

The extent of associations simultaneously possible is restricted.^
The choice of the latter is chiefly decided by the affects, that is, by
the momentary strivings. One of the first results of this is an absence
of the critical faculty and a disturbance of judgment. Recall the
who jumps from a high window to get a cigar butt, and the
paretic
one who steals an object when everyone is looking and then care-
fully conceals it. Another paretic stole a barrel of wine from in
front of a wine shop in bright daylight, and rolled it homewards;
when he became tired, he begged two policemen to help him, and
they went so far in their good nature as to give him his way. A
paretic physician threatened to run away from us; he said that he
could accomplish this very easily in the following way: he would
go walking with us, and then he would step aside for a moment
and not return. When the organic patient in a state of euphoria
comes to an institution and finds a nice room and a friendly attitude,
he very frequently overlooks the entire internment with its element
of force, and declares that he will remain there for such and such
a time. A paretic finds an old bag, cuts up several new ones to
mend it,then gets the idea to make it big enough to reach the ceil-
ing. Patients at the height of their disease only exceptionally acquire
wisdom through experience. In every institution one is well
acquainted with the variations of the paretic, who for several years
has greeted the physician at every visit with the words: "Next Tues-
day my wife will come and take me away."
Complicated pictures can sometimes no longer be grasped in their
context; the patient counts up details and in this respect then reminds
one of imbeciles.
'Cf. p. 100 and following.
'Cf. p. 74.
The various intellectual abilities do not disappear uniformly, but
at present no other rule can be stated except that especially developed
and practiced abilities escape the general deterioration the longest.
The bookkeeper can be markedly demented in all other direc-
senile
tions and yet surpass many a healthy person in addition. A paretic
physician, who had previously made quite a name for himself as a chess
player, when he seemed completely childish, could
in all other respects
still announce to a less skilled player at the opportune moment: "In
ten moves I will checkmate you on this particular square," and he
was nearly always right.
The psychic processes are usually more or less retarded, even aside
from the torpid conditions evidently directly based on the disease
process. But the retardation can, in certain respects, be over-com-
pensated by manic moods with their rapid succession of ideas. Some-
times the patients evince distinct difficulty in passing from one topic
to another. In the later stages the tendency to perseveration exists,
in severe cases so strongly, that a patient, for example, answers the
most varied questions about his personal details with "61," after he
has given the year of his birth with this number. Intercurrent stronger
associative disturbances are the bases of the deliria and states of
confusion.
Of the disturbances of euphoria those individual concepts are
naturally most strongly affected which are in themselves difficult of
access, indefinite, and hard to determine. In place of them the patients
reproduce simple, vague and general ideas such as: "building" for
sunmier house, "man" for carpenter. Their answers to questions are
also characteristically indefinite as shown by the following: "Where
do you come from now?" "I have come forward from in back there."
"Where is "Why, it is in this city." Such answers
our institution?"
are not given in the manner of intentional evasion but with a good
natured sincerity. The patients are evidently satisfied with them and
expect the questioner to feel the same about them. Very often the
form of the answer is influenced by the mood: "In what ward are
we now?" "In a nice one." "What sort of people are they?" "The
right sort of people." In other cases a more or less conscious em-
barrassment is shown, which, however, does not really change the char-
acter of the answer: in the case of questions concerning the date, the
patients have not seen the newspaper or the calendar just of today,
or refusing to recognize the significance of the question, they turn to a
companion and ask him to give the answer, etc. This symptom also is
especially marked in cases of senility.

The affectivity is labile; it manifests itself more strongly and
quickly than normal (emotional incontinence) but emotional excite- :
ments pecter out more readily, either spontaneously or because the

patient is led to think of something else. In the latter case, too, a
lively mood may be supplanted by another without leaving any trace,
often in a few seconds; the actual emotion dominates the patient

absolutely. Trifles make him happy or desperate. A paretic woman
seriously attempted suicide because her husband was late for a meal.
To the extent that the insight for complicated relations is absent,

these, naturally, can no longer become accentuated with feeling. The
feeling reaction is easily restricted to certain fields also by the de-
crease of associations, and the patients appear indifferent, although the
defect is not really in the affective element. A general brain torpor
naturally expresses itself also in the affectivity; on the other hand,
other patients have an exaggerated general excitability, and conse-
quently also an affective excitability. The egotistic interests are
naturally among those most difficult to suppress. As these patients
cannot easily or at all think of other corrective ideas, especially con-
trast ideas in conjunction with their egotistic ones, many appear
egotistic in their thoughts, feelings and acts. This is particularly evi-
dent in the simple senile forms while in erethic and manic conditions,
;
which occur- especially in paresis, the more varied change in thinking

over-compensates this tendency.
It is usually said that the ethical feelings of the organic patients
deteriorate early and very markedly. I believe this is wrong. Some of
these patients, no doubt, commit all sorts of crimes, but to the ex-

tent that they were previously decent according to my experience
they commit them because they no longer have an insight into the
entire situation and its consequences. If they can be made to compre-
hend what they have done, they regret it in the normal way. If
they previously had anti-social tendencies, the disappearance of in-
hibitions naturally permits these to become more easily dangerous.
The cooperation of this labile affectivity with the restricted re-
flective abilitymakes purposeful action impossible. Tenderness, con-
sideration, tact, piety, aesthetic sensibility, sense of duty, sense of
right, feeling of sexual shame all these may any moment, even
fail at
when they are present. Any sort of impulses from within and without
are translated into action without any restraint.
Acute manic and melancholic moods, lasting for months and some-
times longer, appear frequently. The mood, chronic throughout the
entire course,may also be a morbidly euphoric or depressive.
Corresponding to this condition of affectivity and the restriction
of associations, the positive as well as negative suggestibility is height-
ened; on the one hand such people are easily influenced and, on the
other hand, they are stubborn.
Apperception is retarded and unclear. The patients require more
time to recognize pictures and often deceive themselves anyway fail- ;
ures to recognize are sometimes caused by perseverations. Things read

are easily perceived imperfectly and incorrectly. Questions to the
patient often must be repeated and are sometimes answered in the
sense of the previous trend of thought.
Orientation as to time and space often also, the autopsychic, is
disturbed. The patients lack the "inner clock." Many of these

patients no longer differentiate whether they or others are being
spoken to, which is also a part of disturbed orientation. When pre-
sented at the chnic, for example, many, like patients in alcoholic
delirium, answer regularly, when one speaks to the audience.
Attention,^ from the restricted extent, is made diflBcult;
aside
this is seen more in the habitual and the passive than in the maximal
and the active attention. The intensity of the latter may be normal,
even if the extensity has already suffered severely. Sometimes
vigility is reduced at the same time with tenacity.
If Delusions are present, they obtain as a rule the character of
senselessness in the severe cases. Among the depressive delusions one
observes commonly exaggerated ideas referring to diseases; the delire
d'enormite and nihilism when present are especially characteristic.
Hallucinations usually affect sight and hearing. Corresponding to
the brain process other kinds of parasthesias also occur, which, under
certain circumstances, attain a similarity with real (body-) hallucina-
tions. This is usually brought about through misinterpretation
in a state of delirium. Many of our patients are excited and
hallucinate at night, while during the day they are quiet or actually
sleep.
With depressive patients, screaming throughout the night, lasting
for months, is not rare, and generally, stereotyped whining and com-
plaining are nowhere more pronounced than here.
Severe anxiety attacks with senseless or confused reactions, push-
ing away, clinging, brutal, and often clumsy attempts at suicide, hiding
away, hitting at random, etc., are in part results of the brain disease,
and in part probably results of disturbances of the circulatory
apparatus; at all events they are most frequently seen in sufferers
from .arteriosclerosis.
Besides, various kinds of delirious, perhaps also of tmlight states
occur, which under no circumstances manifest the same genesis. We
*Cf.p. 134.
find them as intercurrent symptoms of paresis; in arteriosclerotic

psychosis especially after the inception of diffuse softening, etc.
The organic psychoses are usually accompanied by phynical symp-

toms, which are, in part, the result of the brain affection (paralyses,
trophic disturbances), in part concomitant manifestations (senile
marasmus, neuritis). An irregular coarse tremor, especially of the
hands and the organs of speech, is most constant.
As physical symptoms one often designated also the "nervous"
manifestations which can mark the beginning of every organic in-
sanity. Among these we have: pressure in the head, headache,
parasthesias, flickering of the eyes, buzzing in the ears, etc. Later
they are in part concealed by the deeper psychotic symptoms or in
delirious conditions they are misinterpreted as illusions and delusions
referring to the body.
The disturbance of memory most often characteristic of the
is
simple forms of dementia Here one sees cases in which the

senilis.
limits of absence of memory may be determined to sonie extent. For

instance, the patient does not remember anything that occurred in this
century. After a while the memory gap extends back to the nineties
of the last century, then to the eighties, etc. If only memories of
youth are present, they often have a greater freshness than under
normal conditions; they may even attain an hallucinatory^ vividness
so that the patients believe they live over scenes which in reality took
place seventy years ago. In arteriosclerotic forms irregular fluctua-
tions of memory disturbance, both as regards content and time, readily
occur. In paresis the difference in the ability to recall earlier and
fresher experiences is sometimes not so striking as in the senile forms,
but it can be invariably demonstrated, even though sometimes it first

appears only when the dementia becomes deeper. Alcoholic Korsa-
koff's disease when it is acute usually shows at first a well defined
limit of the ability to recall at the beginning of the disease; the patients
have at their disposal nothing that occurred since ; what occurred pre-
viously they recall pretty completely. However, this demarkation
becomes blurred rather quickly, in that earlier experiences also are
not remembered at all or incorrectly. In the magic form of paresis
and alcoholic Korsakoff, confabulations often appear altogether with-
out any restrictions. In many torpid forms of the senile psychoses
confabulations are almost absent. Other things being equal it in-
creases and decreases with excitement and activity.
The absence of the critical faculty appears to be, on the whole.
more pronounced in paresis than in the senile forms, where the per-
sonality with its strivings in relation to the elementar\^ disturbance
is often better preserved, to the extent that a miserly old man, for
example, is not easily talked into making gifts, etc. The uncertain
answers, which are to disguise the dearth of ideas, are found most
frequently and in a most pronounced form in the simple senile dements.
Coarse brain lesions lead most readily to marked perseverations.
The productivity of the delusions in manic paresis is enormous but
in the other forms it is very limited. Moreover the phantasy forma-
tion in paresis and in alcoholic Korsakoff is usually very vivid, else-
where it is rather reduced.

The lability of the affects also occurs frequently as the result of a
hemorrhage in the thalamic region; it may then remain as an isolated
symptom, in that the intelligence is not affected at all or only after
months and years. In paresis there is a marked tendency to euphoric
moods, and in the senile forms to depressive moods. Alcoholic Korsa-
koff cases are usually very euphoric for a long period.
Apperception is often preserved much longer in the simple senile
forms than in paresis.
Certain variations of the organic forms are often determined by
congenital predisposition of the brain thus emotional people, especially
;
members of families with manic depressive tendencies, more readily

have affective forms of paresis and of the senile psychoses; indeed,
even the depressive or manic dispositions become particularly marked
by the addition of the brain disease; paranoid forms occur in patients
who have always been distrustful and inclined to false interpretations,
while schizophrenic forms in those who originally belong to the schizoid
type, etc. Nevertheless the kind of process has its influence also;
thus paresis inclines to euphoric states, arteriosclerosis to depressive
and anxiety states; delusions of stealing is an organic-senile mani-
festation, not a constitutional symptom, etc.
Corresponding to the underlying brain disease the outcome of

organic psychoses is usually fatal. Intoxication psychoses, like Korsa-
koff, can improve more or less, or after a slight improvement remain
essentially stationary. In spite of a course which is progressive on
the whole, remissions in paresis and in the arteriosclerotic forms may
go very far; in the latter the particular improvements can also last
only a few days or hours; but then they are usually more frequent
and constitute an important element of the entire picture; this is
probably the only occasion on which one can properly speak of "Lucid
intervals." The prognosis of particular senile diseases will be
discussed later.
A differential diagnosis of the organic psychoses is not easy in
the beginning. The disease must already have attained a certain
height before a large part of the disturbances mentioned become evi-

dent. Orientation, for example, in patients whose sensorium is clear
is only falsified in the more advanced stages of dementia. But it may
also happen that intelligent witnesses in court pronounce a man en-
tirely capable of action who, literally, mistakes niglit and day and
wants to go to his office at eleven o'clock at night and closes his office
in the forenoon. On the other hand in senile dementia the difficulty
lies in the fact that normal senility indicates similar symptoms: One
does not know at what stage of memory disturbance or of affective
lability one should count the beginning of the disease. In these cases
practical reasons must sometimes serve as criteria.
If a pronounced melancholic condition exists, then a petty reaction
to minor affairs like a belated meal, or a striking affective distraction,
perhaps by a joke, point to organic lability.
More important still is the nonsense of the delusions and here espe-
cially the form of nihilism and of the Delire d'enormite. Disturbances
of orientation may naturally only be evaluated in cases where it occurs
in a clear sensorium. Nocturnal excitements with sleeping by day
must be weighed carefully because they also occur elsewhere, e.g.
sometimes in schizophrenia. Slow functioning of the psychic proc-
esses, even though of a somewhat different kind, occurs in epilepsy,
where one also sees blurred perception and perseveration.
States of organic unclearness can be recognized most conspicuously
by a good affective rapport with a declining intellectual rapport; this
is differentiated from epilepsy by the fact that fluctuations of emotional
reaction readily occur. Usually the patient is eagerly occupied with

any obviously foolish action, which is to be designated as imaginary,
since it is not based on hallucinations. The patient endeavors, for
example, to fold the comforter, he succeeds, which he rarely does,
if
or if we fold it for him, he nevertheless continues in exactly the same

way to fuss around with it.^
Frequently while the diagnosis of the organic disease is not yet

possible, the specific manifestations, especially physical symptoms like
neuritis, pupillary and speech disturbances (Korsakoff, paresis) permit
a definite diagnosis of the special psychosis. More frequently the
reverse holds true; that is, the "organic psychosis" can be generally
recognized while the specific symptoms of a definite form are still lack-
ing. The view of the fact that there are
latter is especially true in
also organic psychoses resulting from brain diseases which are not
yet known.
An important means of recognizing and differentiating organic dis-
"Comp. presbyophrenic delirium, pages 290 and 294.
;;

turbances of the central nervous system is the examination of the
cerebrospinal fluid. The lumbar puncture also has therapeutic signifi-
'
cance in various diseases. But one must be cautious, especially in brain

tumors, because of the danger that the medulla oblongata may be
pressed into the occipital foramen, and in traumatic neuroses, in which
new complaints may be attached to the operation.
The technique of puncturing should, in the interest of the patient,
be learned by practical demonstration and initial practice under super-

vision. To refresh the memory the following points are mentioned
here: If a line is drawn on the patient's back connecting the two
crests of the ileum, then directly over and under this line one finds
the space between the third and fourth and the fourth and fifth lumbar
vertebra^, respectively, one of which is selected for the puncture. This
is the region of the cauda equina, so that injury of the cord is impos-
sible. Disinfection of the region must be most carefully done. The
puncture needle should be at least ten cm. long and as thin as possible
the elastic instruments of platiniridium are the best. In the insane
it is often an advantage to puncture them while in a sitting position,
because it is easier to hold them, and because they are usually less
excited than when they are put in a reclining position; in both cases
the most important item is the very decided flexion of the spinal column
("hump back") because then the inter-vertebral spaces open; but the
spinal column must not be turned laterally because the location of the
spinal canal is then more difficult to find. The sitting patient is best
placed so that he sits backwards on a chair and throws his arms around
its back; an attendant kneels in front of him and holds his legs sym-
metrically upwards. The puncture is made either in the middle line

directly under the third or fourth lumbar spinous process which is
located with the finger of the free hand. The direction of the puncture
should be slightly oblique tending upwards; the lateral method pene-
trates a little deeper, one cm. beside the middle line. In the first case
one has the great advantage that one must puncture directly in the
middle line without a lateral deviation, while in the lateral puncture
the correct estimate of the angle requires more practice; on the other
hand, in the median puncture one must go through the hardest part
of the ligaments which occasionally may deceive with a resistance
equal to that of bone. Frequently the puncture is made too deep;
then a slow withdrawal of the needle suffices to permit the outflow
of the liquor which had apparently not been reached.
For purely diagnostic purposes six to ten ccm. should be withdrawn
in cases of paresis one can usually go a little higher without disagree-
able consequences. Rapid decline of high pressure even after a slight
emptying indicates clanger because of defective communication between

the cerebral fluid and spinal canal.
one wants to measure the pressure of the liquor, one must nat-
If
urally do that first and with the patient lying on his side. One at-
taches to the needle a sterile tube of small calibre with a glass attach-
ment, lifts it as long as the fluid in the glass attachment rises, then
one measures the height from the point of puncture with a scale held
alongside. The normal height varies between 90 and 140 mm. HÔ.
In case of very high pressure the withdrawal should be retarded and
ended before it has come to the normal height.
After the puncture
the patient should bed for 24 hours in about a horizontal position.
lie in
If there is slight temperature or headache or heaviness in the head,

as occasionally happens, he should remain in bed two or more days
and take, perhaps, some pyramidon (0.2 to 0.3 per dose).
In the normal person the fluid is clear and colorless; intermixtures
of blood resulting from the puncture settle quickly when permitted
to stand. (Sera containing blood are naturally useless for the Wasser-
mann reaction.) In yellowish discolorations that do not come from
bleeding of the puncture, bleeding of the brain should be thought of
especially, then of cerebral inflammation and pachymeningitis. Count-
ing the celhilar elements of the fluid must be done as soon as possible,
as otherwise they turn to sediment; it is best done with the blood cell
chamber as modified by Fuchs-Rosenthal, which has a depth of 0.2 mm.
instead of 0.1 mm.; as a stain, for example, one can use Methylviolet
0.2, Acid. acet. glac. 1.0, Aq. dest. 50.0. The normal number is to 5
cells in the cubic millimeter; 6 to 10 is suspicious; what exceeds this
number may be considered pathological. A psychosis with an increase

of the cells is generally paresis. If one wânts to differentiate the in-
dividual cell forms, one had better stain according to well known
methods after the fluid is centrifuged. Plasma cells found in a
psychosis usually indicate
paresis. Still more important is the Wasser-
mann reaction of the serum, in which the evaluation with different

doses of liquor is frequently necessary. In paresis the reaction is
usually strong; in lues of the central nervous system it is frequently

weaker.*' Chemically, Nonne's "Phase I" is significant: About 1 to
2 ccm. of the fluid are mixed with an equal amount of a saturated
aqueous solution of ammonium sulphate, not warmed: In central
syphilogenous diseases a discoloration or at least an opalescence ap-
pears,which proves the increased presence of globulin and nuclein.
If it then boiled the remaining albuminous elements precipitate
is
(Nonne's "Phase 11") but the latter examination is better made with
,
"See page 248.

Nissl's graduated tube, in which 2 ccm. of the fresh fluid is replaced by
1 ccm. of the common Esbach reagent and then centrifuged for one
half to three quarters of an hour the precipitate gathers at the bottom
;
of the tube and can be removed; the normal liquor hardly contains
more than 0.2 to 0.35% of albumin; in pathological conditions a two-
fold or greater increase frequently occurs.
Phase I is regularly positive (opalescence) in paresis, congenital
syphilis, in extra medullary tumors, a little rarer in tabes and other
luetic forms of the central nervous system, only in some cases of brain
abscess and other diseases of the brain, spinal cord, and its meninges.
According to Kajka ^ the chemical diagnosis may be carried fur-
ther. The Globulines, which already separate when a 28% saturated
solution of ammonium sulphate is added, indicate acute meningeal
inflammation but do not exclude tubercular or luetic processes. The
whose presence proves paresis,
euglobulins (fibrinogen, fibrinoglobulin) ,
still separate with reagents saturated to 33%. The pseudoglobulins

only occur in chronic lues cerebri and only become visible with the
application of a solution saturated to 40%. ^-L^
I. INSANITY IN INJURIES TO THE BRAIN \
In the confusing mass of external pictures resulting from brain

injuries onestill misses a systematic viewpoint. A few types that I
mention, following Kraepelin, may give an indication of what occurs
in this connection.
Concussion of the brain with its symptoms of unconsciousness,
collapse, vomiting, etc., is familiar to physicians from the study of
surgery.
Traumatic delirium or commotion psychosis. A delirious state
sometimes follows directly after the accident or brain concussion in
which disturbance of memory of the organic type, or traumatic in un-
injured brains of curable Korsakoff, is usually plainly recognizable;
sometimes it is connected with nervous symptoms like headache, dizzi-
ness and with focal symptoms that do not always indicate a tangible
anatomic brain injury. The state of affectivity varies. The disease
usually lasts only a few hours or days, occasionally several weeks,
the last especially when it has developed only after days or weeks
after the trauma. Later one observes usually a lack of memory with
a tendency to retroactive amnesia.
'Munch. Med. W. S. 1915, p. 105.

Besides Kraepelin, comp. Schroder, Geistesstorungen nach Kopfverletzungen,
*
Enke, Stuttgart 1915.

As transitional states during improvements, and more frequently as

a chronic state, that can attach itself to the trauma immediately or
after a longer latent period even without a commotion psychosis, we
notice different pictures of traumatic states of weakness. Common
to most them are rapid exhaustion," irritability, tendency to spon-
of
taneous and reactive moods, up to the most intense anger, which is
in part labile and in part of a more torpid persistent affect; more
rarely we notice a stupid euphoria with a mania for joking (Moriaj.
Not rarely epileptic attacks appear in which the typical epileptic
dementia may occur (traumatic epilepsy).^" Pictures similar to Cata-
tonia can last for a long time. Even after a long time subdural or
cerebral bleedings with the consequent manifestations can occur.
Not very rarely milder injuries to the brain cause indefinite symp-
toms that give the appearance of a neurosis.
In children injuries to the brain readily lead to idiocy, especially
to the irritable forms with moods.
Berger^^ differentiates (1) commotion psychosis, (2) traumatic de-
mentia, and (3) traumatic twilight state. He divides commotion
psychosis into (1) hallucinatory confusion, (2) those with the Korsa-
koff (=organic) symptom, (3) those with a manic tinge, (4) those
with catatonic symptoms.
The treatment of these conditions unfortunately is not very suc-
cessful. In the delirious forms the only thing that can be done is to
await recovery and protect the patient from himself. In the chronic
forms it is important to abstain from alcohol which enhances the symp-
toms and causes excitement. It should also be kept in mind not to
give such people cocaine injections (dentist!) because permanent
epilepsies may be released as a result. The excision of a scar from
the brain (more frequently from the meninges), leaving perhaps an
opening as a pressure vent, is said sometimes to effect a cure especially
in the epileptic forms; perhaps more frequently the same may be

Under certain conditions, e.g. in continuing to add numbers, many of these
patients seem to tire less than the normal, apparently because they do not
concentrate.
^
The numerous "war epilepsies" do not confirm these peace epilepsies.
However, on the one hand, the time since the war is still somewhat short on ;
the other hand, the various brain attacks which do not belong to our concept

of epilepsy are here included for the present, because it is not quite possible
to differentiate them, as the different kinds of attacks frequently change from
case to case and even in the same patient (comp. e.g. Jacksonian Epilep. p. 342).
Cf. also Forster on later clinical experiences with bullet injuries of the brain
in the Handbuch der arztlichen Erfahrung im Weltkrieg, Barth, Leipzig, 1922,
IV, p. 198.
" Trauma und Psychose. Springer, Berlin, 1915.
effected by a removal of a bone splinter irritating the brain. Bromide
is sometimes effective against irritability. It is still more important
to be extremely considerate of the patient and to avoid every irritating
circumstance. Headache and similar symptoms frequently only be-
come worse through treatment, while ignoring it may make the con-
dition more bearable. In addition a suitable selection and education
of those persons who are wont to come in contact with the patient is
necessary. It is taken for granted that the patient is trained and
practiced in a line of work carefully adapted to his abilities.
n. INSANITY IN BRAIN DISEASES

These psychoses also have little significance for psychiatry. The
thing that is essential from a practical viewpoint is usually the basic
disease; but the psychosis must not be overlooked because of the pos-
sibility of its being mistaken for other mental diseases and neuroses.
Diffuse nutritional disturbances of the cortex in every case result in

the organic syndrome.
In connection with the psychical disturbances4a~thLjy^rious forms
of meningitis, Kraepelin discusses the insanity in cases of brain tumors.
Here too the most different disturbances have been described, and
the connections between the tumor and the psychosis are not often
clear. may remain with hardly any psychic symptoms
Large tumors
or at any rate may
run a course without any severe manifestations.
Brain pressure retards all reactions, but need not disturb them in any
other way. I have seen a case in which it might take five minutes
before the patient answered a simple question; but the answers were
appropriate. Of theoretic interest, even though still incomprehensible,
is the frequent occurrence here of the "facetiousness," which perhaps
appears as a local symptom of the base of the frontal lobe. It is
interesting also that, according to Schuster, tumors of the corpus

collosum are regularly connected with psychic disturbances.
Where pronounced psychical morbid pictures are found in tumors,
it is usually a case of the organic symptom complex (lability of the
feelings, Korsakoff memory disturbances, etc.) for comprehensible
reasons, because the nutrition of the brain is easily disturbed in toto.
Under circumstances still unknown, catatonic symptoms may also be
connected with brain diseases, especially with tumors.
The disturbances of the psyche in multiple sclerosis are mainly
those of the organic psychoses. In the field of affectivity, irritability
is often in the foreground; in other cases it is euphoria, or the reverse,
depression. In most cases the diseased is animated by psychogenic
neurotic symptoms; since these are amenable to the right psycho-

therapy it is very important, and usually very easy, to recognize them.
In later stages delusions and delirious conditions may also be seen.
The diagnosis is based on the neurological signs of multiple sclerosis.
Huntington's chorea, which is almost always hereditary, is more
important. I knew a family in which four generations were so afflicted.
The transmission is usually of the same variety. But not seldom other
severe cerebral disturbances such as epilepsy, idiocy, etc., are also
found among the relatives. The psychic and motor manifestations,
as a rule long unrecognized, appear stealthily mostly in the second
to the fourth decade, occasionally still later, and rarely earlier. Such
persons are often considered inattentive and careless and are blamed
for their clumsiness, in the appearance of which the motor-choreatic
disturbances participate just as well as the psychical. The chorea in
itself, when it is once pronounced, looks exactly like Sydenham's dis-
ease, only the movements are mostly less brusque. In the psychic
sphere one observes an organic dementia. Often, however, there is a
marked indifference to the disease and about their own affairs which
is generally noticeable. When the patients are no longer capable of
speaking and writing they usually take no pains at all to make them-
selves otherwise understood. Changes of mood are not so rare but they
probably never attain the degree of a melancholia or a mania.
Death results in the course of a few decades during which the severe
mental affliction either progresses steadily or shows minor fluctuations.
The brain shows markcc!)y diffuse changes of the nervous ele-
ments, which as yet have not been sufiiciently investigated to permit
of an anatomical diagnosis.
Kraepelin includes in here the amaurotic idiocy of Tay and Sachs,
which affects mainly Jewish children in their first year. It is not a
form of idiocy but a peculiar brain degeneration involving the visual
apparatus including the retina and ends in death in several months
or years.
An organic brain disease, which affects the cortex relatively little
and for that reason lacks the organicsyndrome, is Encephalitis leth-

argica, the European sleeping sickness, which has no connection what-
ever with the African sleeping sickness. Anatomically it is a poUencc-
phalitis in which there is a round cell proliferation of the vessels and
in which more rarely there are also slight hemorrhages. Its favorite
location is around the Aqueduct of Sylvius but it also spreads to the
canal root ganglia and their surroundings and invariably descends into
the spinal cord but it probably does not leave any part of the gray
matter entirely free. The physical symptoms are paralysis of internal
and external eye muscles, sometimes also paralysis of the facial nerve,
parasthesias not only in the form of itching, etc., but also pains and
burning, paralyses in general, and mild muscular rigidity. The de-
velopment of the disease is from several days to weeks; fever appears
mostly at the height of the disease; it is frequently not particularly
high and may disappear after a few weeks.
Psychotic symptoms of a toxic rather than organic character
appear chiefly in the initial stage. Thus one observes: motor restless-
ness, which sometimes lends a choreic character to the movements.
This is frequently accompanied by deliria, which resemble the ordinary
fever psychoses, but because of their complex character they may be
readily taken as hysterical, especially before the temperature rises.
In severe cases they increase to the point of apparent confusion. Some-
what later the clouded state often assumes the character of occupation
deliria, which alternate with the ever-increasing lethargic state. In
milder cases one sees at least occupation dreams. Except in the most
severe cases the patients can be roused from their sleep and, after the
disappearance of the initial deliria, evince their meataJr-dearness, even
though strikingly uninterested in their own condition as well as in the
environment. Left to themselves at the height of the disease they
invariably go to sleep aga4n. The^yperkinetic deliria of the begin-
ning are easily mistaken for catatonic especially because, in spite of
existing affects, the facial expression regularly has something rather
stiff about it, and because the torpor may assume a real cataleptic
appearance. The occupation deliria may occasion its being mistaken
for delirium tremens. The disease often results in death in the early
weeks, in many other cases later, even after more than two years.
About two thirds recover almost entirely in the course of a greater
number of weeks or months. But the rigidity of the pupils is often
said to remain permanently. The differential diagnosis is based
mainly on the proof of the following encephaliticsymptoms: paras-
thesias, hyperkinesis v/ith chorea-like movements and above all dis-
turbances of the eye muscle and eventually of the optic nerve; also
then the mania for sleep with the possibility of being aroused to an
intellectually clear condition.
What excites the disease and the manner of infection are unknown;
the treatment is symptomatic.
in. SYPHILITIC PSYCHOSES

Among the infectious diseases of the brain and its meninges syphilis
is the most important. To be sure even without the confirmation of
a luetic process in the central organs there are already disturhanccH

at the beginning of the secondary stages of lues, which are designated
as "neurasthenic." The latter are due in part to the psychic effects
of the infection,which nowadays is no longer taken so light heartedly,
and in part probably to the direct weakening or poisoning influence
of the virus, which to be sure we cannot as yet define more exactly.
Manifold signs of milder disturbances of the nervous system, .such
as dizziness, headache, diminished pupillary reaction to light, an in-
crease in the cells and albumin in the spinal fluid, which are frequently
a result of an antiluetic treatment, lead to the supposition that as a
third factor some unknown early alteration of the brain or of the
meninges can produce or condition symptoms resembling those of
neurasthenia.
Sometimes the thought of being infected and the fear of the conse-
quences of lues form the conspicuous part of the picture. There
develops a hypochondriacal neurasthenia, altogether or mainly psycho-
genetic, withan eager searching for morbid symptoms that might be
ascribed to syphilis.According to some, hysterical pictures are also
said to be produced by the infection.
In other cases, according to Kraeyelin, one deals with a general
nervous uneasiness, increased difficulty in thinking, irritability, dis-
turbance of sleep, pressure in the head, vague and alternating feelings
and pains, later on anxiety feelings, pronounced depressions, dizziness,
clouding, difficulty in finding words, transitory paralyses, disturbances
of perception, nausea, and a rise in temperature. The latter group
of manifestations might perhaps be ascribed to the third cause, or to
some direct anatomical or chemical disturbance in the cranial content.
For a second group of syphilitic psychoses which are about equally
frequent in men and women we have an anatomical basis among those ;
one observes gummata, slowly progressing meningitis, and luetic vascu-

lar diseases. In most cases one of these processes predominates, but
the disturbance is rarely limited entirely to one of them. The vascular
alteration most often found alone but it frequently accompanies
is
meningitis and both together are often found in an affection which is

primarily gummatous. The combinations and the changing intensity
and location of the processes produce a great variety of the clinical
pictures, but the anatomical findings are as yet only roughly paralleled
with the clinical.
The Gummata in themselves naturally produce the identical symp-
toms as other brain tumors of equally rapid growth and similar locali-
zation. Luetic meningitis is mostly localized at the base, especially
in the region where the various optic nerves have their exit, it moves
246 ' TEXTBOOK OF PSYCHIATRY
rarely; also affects the convexity and then usually to a lesser extent.
The variety of symptoms caused by meningitis naturally depends on
the increase of the pressure and the luetic process, or on whether the
disturbances of nutrition extend to the cortex or not. The diseased pia
is usually thickened, clouded, infiltrated with round cells, and shows an
increase in connective tissue.
The vascular changes in themselves produce symptoms similar to
the non-luetic arterioscleroses. They can affect more extensively
either the large or the small vessels. The syphilitic vascular disease
shows itself in the larger arteries in an exuberance of the cells of the
intima and adventitia, in the former to the extent of occluding the
lumen. The elastica becomes split apart. The process has a certain
tendency towards regeneration, but when the arteries of the brain are
involved, the region they supply is usually permanently injured in
the way of a simple gradual destruction of the nervous elements with
an infiltration of the glia to the extent of softenings and hemorrhages.
The process is most marked in the pia and seems to extend from it
to the cortex.
In contradistinction to paresis one notes here a massive infiltra-
tion of the entire vessel with round cells, among which the plasma
cells constitutea small minority or are absent, while in paresis the
marked infiltration of the vessels with plasma cells is particularly
characteristic, and the extensive exuberance of the intima is foreign
to this disease. What is also characteristic is the more circumscribed
dissemination in contradistinction to the diffuse disturbances of paresis.
The luetic arteritis of the smaller vessel often consists in an en-
largement and proliferation of the cells in the adventitia and intima
but without an infiltration of round cells. Side by side with the de-
structive processes one also finds newly formed vessels in the pia and
in the brain.
The brain substance is naturally injured in the most varied ways
both qualitatively and quantitatively by the alteration of the vessels
and the meninges.
The organic-nervous symptoms can assume pretty nearly all forms
that are produced by the contents of the cranium and the spinal canal.
The most frequent symptoms encountered are reflex disturbances of
the pupils, pressure symptoms with clouding of sensorium, desire for
sleep, etc., and apoplectiform and epileptiform attacks as well as
attacks showing a Jacksonian character. The psychic symptoms are
those of the organic psychoses. The specific peculiarities are similar
to those of arteriosclerotic insanity for the self-evident reason that
in both diseases the cortex needs not be affected in toto. The per-
.
sonality is retained for a long timc.'^ The patients maintain tiieir
outward demeanor and take part in external events. Judgment is not

so much disturbed; thus a far-reaching insight into the disease exists,
in quiet times even considerable clearness. As in arteriosclerotic in-
sanity, here, too, the psychic symptoms, both as to time and number,
are lacunary: many good individual functions cause surprise when
found where others have been lost; moody fluctuations can appear
temporarily, regardless of the general course toward improvement or
aggravation.
After all this, no sharply distinguishable morbid pictures can be
expected. It also happens that a genuine brain syphilis can be fol-
lowed later by a real paresis. Kraepelin makes the following distinc-
tions: Forms with brain pressure, mostly based on gummatous
growths, clinically not essentially differentiated from diseases resulting
from other brain tumors, and the syphilitic pseudoparesis (correspond-
ing approximately to the post syphilitic dementia of Binsiuanger)
In the latter it is most frequently a case of a morbid picture very
similar to the sim-ple demented form of paresis in the physical spheres
;
besides the rigidity of the pupils to light, the frequency of irregular

paralyses of the ocular muscles, and disturbances of vision are the
most important to be mentioned. Disturbances of speech and writing
may be present but they then are of a different type from that of
paresis.
Much rarer is the delirious confusion of Marcus which is to be
classed with syphilitic pseudoparesis. It manifests itself in rather
sudden organic deliria with symptoms of insomnia, confusion, anxiety,

mistaking the environment, hallucinations of hearing and sight, mostly
of a terrifying content, active excitement, and acts of violence against
one's own person and others. Besides these one also finds organic
nervous symptoms.
Other forms resemble expansive paresis. The prominent feature
of the fourth group an organic memory disturbance (''Korsakoff'').
is
Syphilitic pseudoparesis takes an entirely irregular course; it can

be stationary for years. The outcome in all cases, when no anti-
luetic treatment intervenes or wdien this is not effective, is an organic
dementia combined with paralysis. The patients die of intercurrent
diseases, or from weakness, or cerebral attacks, or marasmic pneu-
monias, etc.
The differential diagnosis between pseudoparesis and paresis can-

not be made at once in individual cases with absolute certainty. Im-
provement in the course of antiluetic treatment does not exclude the
"Cf. pp. 139-282.
element of coincidence. The probability favoring cerebral syphilis is
the lighter intensity and extent of the psychical disturbances. It

may also be worth noting that in paresis milder psychic symptoms
of "the neurasthenic" typehave in most cases preceded the physical
symptoms, while here both groups usually appear together.
According to Plant the following should be especially considered:
Wassermann in the blood proves lues; its absence permits the exclu-
sion of the possibility of cerebral lues with a probability of 80%. A
pronounced pleocytosis of the spinalfluid in the advanced stage of
an organic (meningitic) process
lues (not in the initial stage) proves
in the central nervous system; the same holds in Nonne's Phase I.
Wassermann in the spinal fluid proves the luetic affection of the central
nervous system; contrasted with the invariably strong reaction in
paresis (already plain in 0.2 ccm. of the liquor) it is here weak; the
fluid must be tested up to 1.0 ccm. Lues cerebri may be excluded with
great probability when there is no Wassermann in tested fluid, an
absence of Wassermann in the blood, an absence of pleocytosis, and,
with least certainty, when there is a failure of the globulin reaction.
Apoplectic cerebral lues is supposed to be the commonest of the
syphilitic psychoses. It presents about the same pictures as the com-
mon post apoplectic dementia, but it appears most often at an earlier
time of life, shows a greater desultoriness and regenerative possi-

bilities of the symptoms, and then again as a sign of brain lues it
shows frequent paralysis of the eye muscles as well as pupillary

disturbances.
Furthermore there is a luetic epilepsy which differs from the other
forms by the existence of lues, its appearance late in life, occasional
(not invariable) cure through antisyphilitic treatment, and finally
by disturbances of the eye muscles.
An entirely divergent form without plain psychic organic symptoms
has been described in detail chiefly by Plaut, as hallucinosis of
syphilitics, but he did not establish with entire certainty the concep-
tion of a particular disease. It is a question of cases which as yet are
not to be differentiated clinically from mild paranoid types with
senseless delusions, voices, very rarely other hallucinations. Halluci-
nations referring to the body probably also occur; the patients some-
times feel as if they were hypnotized. However, pronounced specific
schizophrenic symptoms, especially actual dementia, are absent. De-

pressions with ideas of sin and, more rarely, exaltation of a minor
degree, but still with grandiose ideas, are also met. Usually there is
a certain feeling of sickness. The course is similar to many cases of

schizophrenic paranoid types and shows irregular fluctuations up to
hallucinatory excitations, which, however, remain without disorienta-

tion. Cures do not seem to occur in spite of antisyphihtic treatment.
Sometimes one also notes paralytic manifestations, pupillary dis-
turbances, bladder weakness, disturbances of speech and writing, dizzi-
ness and other cerebral attacks. The disease usually breaks out more
than ten years after the infection.
Plant also described similar acute cases with symptoms of anxious
excitation, with voices and delusions of persecution without disorienta-
tion, which lasted from 18 days to 10 months and usually recovered.
The most important syphilitic affection of the central nervous
system Dementia paralytica. Contrasted with the other luetic dis-
is
eases it has some peculiarities in common with tabes and is not seldom
associated with this disease as taboparesis. But besides this there are
"Tabes psychoses" which neither clinically nor anatomically belong
to paresis. They mostly show mild indications of organic symptoms,
especially lability, but also disturbances of memory, attention, etc.
In all other respects they take very different forms. Following Krae-
pelin affective and paranoid forms are mostly differentiated, of which
the latter are the more frequent.
Theaffective pictures manifest themselves in persistent moods, in
the form of depression,, irritability, or abnormal euphoria. The
paranoid jorms develop vague delusions, usually of persecution, inter-
mingled at times with delusions of grandeur; they also have hallucina-
tions of hearing and occasionally of sight, more rarely of smell and
taste and of body sensations.^^
Even in the chronic course, these conditions show a rather marked
fluctuation; on the other hand cases are not rare in which the disease
manifests itself only in acute shifts of such hallucinations and delu-
sions mostly with anxious excitements extending to the point of
delirium. Between these forms there are all combinations and transi-
tions, i.e. cases in which the delusions continue more or less in the
clear state and now and then one also observes deliria. In clear mental
states all these patients are usually allopsychically oriented.
The much more frequent occurrence of disturbances of the visual
nerves in tabes with psychoses than in mere symptoms of the spinal
cord makes it probable that the tabes psychoses also are based on a
variety of cerebral lues.
Hereditary syphilis also generates numerous brain diseases, which
are associated with psychicsymptoms, they range from simple nervous-
ness up to idiocy, epilepsy, infantile paralysis, and other progressive
forms of dementia which have not been properly described as yet.
" Cf. pp. 64-65.
According to Kraepelin a part of the luetic idiocies already origi-
nated within the uterus, chiefly through meningo-encephalitis; others
develop later, some suddenly, others gradually; later they may again
become stationary. Local disturbances of the brain texture, e.g.
through arterial occlusion, naturally leave pictures similar to those
of acute encephalitis. According to some about 10% of idiocies
are conditioned by syphilis. In some, besides severe or very slight
intellectual disturbances, one finds chiefly anomalies of character,
vehemence, maliciousness, cruelty, and uneducability in general.
Under certain circumstances paranoid pictures In all also appear.
these forms the entire constitution mostly impaired; the children
is
develop late, remain weak, small, or deformed. The luetic cerebral

symptoms may appear at any time, but most frequently in the first
years. But infantile paresis may first begin in the second decade; in
very rare cases the outbreak is said to have been delayed to the fourth
or fifth decade.
The diagnosis of paresis in children rests on the same principles
as in adults. The proven
other hereditary syphilitic forms are first
as definitely syphilitic by the success

therapy or by the anatomical
of
examination. At all events the specific origin is indicated with great
probability by the demonstration of syphilis, such as direct luetic
manifestations, positive Wassermann, Hutchinson's triad, namely,
semicircular lower edges of the middle upper incisors, keratitis
parenchymatosa, and sudden deafness in childhood, further by the eye
symptoms and by the fluctuating progressive course.
IV. DEMENTIA PARALYTICA

Dementia paralytica, which is commonly incorrectly called soften-
ing of the brain and in science briefly, paresis, is a peculiar syphilitic
brain disease with the general symptoms of the organic psychoses and
peculiar physical manifestations. It mostty runs a course of a few
years and ends in death.
Besides the above mentioned ^* psychical peculiarities which differ-
entiate paresis from the other organic psychoses, there are still others,
but as yet it has not been possible to isolate them clearly, and still less
to formulate them. ^
On the other hand the physical symptoms of paresis are plain
specific signs. Just as in tabes we find reflex rigidity of the pupils
(Arg>'ll-Robertson) ; that is, the pupils react to light slowly or slug-
gishly or not at all, while reaction to accommodation is usually longer
or better preserved. The pupils are frequently unequal, abnormally
"*
Cf pp. 235-236.
.
dilated or abnormally contracted, and not seldom changed in form.

Psychical pupillary reaction (to pain, mental exertion) is also im-
paired, but not to the extent that these disturbances would show a
proportionate relation to the reflex rigidity of the pupil or to the stage
of the disease.
The remaining reflexes have nothing characteristic about them; the
tendon reflexes in simple paresis are naturally exaggerated because
their control through the cere-
brum is diminished; when com-
plicated with tabes, that is,
when there is an interruption

of the peripheral spinal reflex
arc, they are absent at least in
the lower extremities.
The coordination of muscu-
lar action suffers in a striking
manner which is most pro-
nounced in the delicate adjust-
ments of the movements of
speech. Individual sounds are
badly formed, successive sounds
are "run together," the patient
prolongs the semi - vowels,
sounds and syllables are omit-
ted, repeated, or misplaced
(stuttering of syllables), and
occasionally the sound compo-
Fig. 1. The typical flabby paretic ex-
pression. It looks as if the mimetic
nents of a word are changed.^^ modelling had been erased by excessive
The psychic disturbances are retouching, while the eyes betra\' an af-
fective life. If the ej'es are covered, the
naturally also present, since face looks like that of a sleeper. Asym-
inattention and weakness of metrical noso-labial folds.
impressibility or amnestic diffi-
culties, make repetition as well as spontaneous speech more difiicult.
Especially in the later stages, the voice easily becomes trembling,

monotonous, and towards the last speech is usually slow, babbling,
and hardly comprehensible.
In many cases the tone of the mimetic muscles decreases, the naso-
labial folds seem wiped out (often more so on one side), the finer
"Ziehen speaks of "hesitating speech." It is, of course, correct to say that

paretics speak slowly as soon as coordination becomes seriously difficult but ;
the term should be limited to the entirely different epileptic speech disturbance
to which it is better suited.
;

mimetic movements are lost. As a result the face assumes a flabby
and stupid expression, which often enables one to recognize the paretic
immediately. Even earlier tremors of individual groups of the facial
muscles are sometimes seen ("Heat lightning").
The tongue is often put out hesitatingly and shows tremors of
individual muscle groups.
The handwriting is changed in an analogous manner to speech.
Aside from the frequent coarse and irregular tremors of the organic
brain affection the lines do not go where they should; the letters be-
come abnormally large and long and unequal; curves are made with
corners, etc.; pressure
is irregular. The psy-
chical difiiculties are
as follows: omissions,
repetitions, inter-
change of letters, syl-
lables and words,
blotting, wrong cor-
rections, incorrect syn-
tax, the end does not
fit the beginning of
the sentence and, fi-
nally, only an illegible

scribbling is produced.
Disturbance of the
Fig. 2. Paretic.
In spite of a strained pose, ex-
gait usually becomes
pressed in the frown and eyes, the part of the face
below the eyes remains flabby. plain somewhat later,
unless tabes with its
characteristic signs of the psychosis precedes. The foot misses its
mark, deviating now to the front, now to the rear or side ways.
Thus the walk becomes irregular, swaying, with legs spread apart,
and at the same time weak, and in certain respects spastic (but not
in the sense of spastic spinal paralysis with its difficulty of freeing the
tip of the foot from the ground) . Inequality of the two sides, "hang-
ing" of the entire body to the left or right is not rare. In the last
stages walking is generally impossible.
Gradually the entire muscular system attains a condition of ex-
treme spastic paralysis; the patient becomes entirely helpless. The
involuntary muscular system is also affected: swallowing becomes
difficult and impossible the intestines no longer advance their content
;
more frequently incontinentia alvi et urinae exists, the latter often

together with paralysis of the bladder.
UÂOfi^
Figs. 3a and b. Paresis.

Paretic script. Disturbance of coordination is espe-
cially plain in the M. and
the H., the former showing it by the intemiptions in
the lines, numerous but vain efforts to continue the strokes. This is particularly
seen in the letters r and in the word beautiful, which is hardly legible. In example
(b) one sees besides some reduplications of strokes and letters and a fusion of
letters, etc.
The blood in most cases shows a positive Wassermann, the liquor
cerebro spinalis nearly always. The latter ^^ is mostly under increased
pressure and because it contains globulin it is clouded by the addition
of an equal amount of saturated solution of ammonium sulphate
(Nonne, Phase I) ; it abnormal amount of albumin
also contains an
(Nissl reaction with the Esbach reagent) and shows always a hyper-
,
lymphocytosis, in which the presence of plasma-cells especially (and

eventually broken-down cells) is said to be important for the special
diagnosis. The number of cellular elements may rise in paresis to
several hundred in the cubic millimeter.

The above mentioned physical symptoms must be classed with
the fundamental symptoms of paresis, even though in very rare cases
they may be only indistinctly evidenced throughout the entire course.
Neither in the time of appearance nor in regard to their intensity
is there a definite correlation with the psychic defects, and they may
appear earlier or later than these. Disturbance of coordination is
not seldom found afterwards in earlier specimens of the patient's hand-

writing, and the pupillary disturbances especially may manifest them-
selves years before the outbreak but may be lacking in a pronounced
psychosis.
Among the accessory physical symptoms the paretic attacks are
most frequent. They resemble those of other severe brain diseases.
Mostly, but not always, they appear suddenly; consciousness is usually
lost and then convulsions appear, in part general, in part somehow
localized, sometimes also they are of the Jacksonian type. There is
no "striking blindly" as is so common in epileptiform attacks. They
may last for seconds or for days, and consciousness often returns before
the convulsions cease.
Besides these attacks, which are characteristic of gross brain lesions
in general, mere fainting spells, epileptiform and apoplectiform attacks
occur. The latter may or monoplegic paralyses,
leave half sided
which mostly have a spastic character and need not be based on ascer-
tainable anatomic lesions, even when they no longer disappear, which
is the exception. Attacks of fever lasting for hours or days may be
based on abnormal conditions of the heat centers or on a sudden in-
crease of the spirilli.
Aside from decalcification of the bones various kinds of trophic

disturbances occur. Decubitus cannot sometimes be avoided in the
final stage, not only because of the paralyses and uncleanliness but
because of trophic changes. Othaematoma may also appear without
the application of violence.
"Comp. pp. 238. etc.
;
THE INDIVIDUAL MENTAL DLSEASES 255
The weight of the body is strongly influenced by the diseaHe; the

euphoric forms are mostly well nourished, sometimes till death; but
usually marasmus appears in the final stage of the disease. Other
cases are marasmic from the beginning.
The appetite is at times excessive, at times lacking, as a rule
fluctuating with the prevalent mood exaggerated
; gorging often exists,
especially in the demented stage of the manic form.
Sleep is very variable; in all excited states it is naturally brief;
in the quiet stages preceding the deep dementia it is mostly normal;
in the last stage the nights easily become restless. Pathological sleepi-
nessis much rare.
The sexuaUty is usually changed; in the beginning of the manic

forms the libido is mostly increased, later potency disappears first,
then, also, the desire.
Like tabes, paresis also is sometimes accompanied by optic atrophy
which, however, may fluctuate strongly in a striking manner, that is,
vision, in the course of months becomes worse and better; total blind-
ness is an exception. Paralyses, mostly transient, of individual eye
muscles are not so rare (especially in the incipient stages) ; definite
degenerations of individual nerve roots may occur.
Sensory symptoms in the form of headache, ordinary" and "ophthal-
mic" migrain, and other parasthesias are not rare and are prominent,
especially in the preparatory stage, where they are taken for neuritis
and rheumatisms. The very frequent hypalgesia or analgesia which
mostly affects only the skin, is diagnostically important.
Among the psychic accessory symptoms endogenous affective
fluctuations of the manic or melancholic type dominate the external
picture so frequently that they have been used as characteristic of
sub-groups.
Hallucinations (almost entirely of sight and hearing) do not play
a large part; most cases run their course without them. Only rarely
are illusions prominent for any length of time.
On the other hand delusions are frequent and are mostly connected
with the emotional shiftings. They are not nearly so fixed as in the
paranoid conditions, and especially in the manic forms they change
in extent and intensity with the strength of the affective fluctuations
and the weakness of judgment; they also increase through preoccupa-
tion with them. The patient has the idea that he owns twenty horses
as soon as he has imagined this, it is not enough and he owns one
hundred, then two hundred, etc. Delusions may also be provoked or
modified by remarks: The patient is asked whether he did not have
a rank in the army and he readily becomes a general- They are sense-
less, partly because of the enormous exaggeration, partly qualitatively:
A paretic wants to become rich by purchasing a house with a mort-
gage of $70,000, that pays $1600 interest; he wants to earn a million
with a toboggan slide: "Admission with a bottle of fine wine two
dollars." Another buys for his own use one hundred cases of maca-
roni and all sorts of perishable things in similar quantity, he orders
"a boat load of champaign."
In some cases severe focal symptoms are noticed, indefinitely cir-
cumscribed paralyses of the cerebral type {facial nerve inequality espe-
cially of the lower branch is very frequent) aphasic and apractic dis-
,
turbances, etc. In the later stages manifestations of irritation as

smacking the lips, grinding the teeth and other spasmodic, more or
less coordinated movements sometimes appear.
Especially in the final stage, symptoms also occur that externally
look the same as those of catatonia and cannot as yet be properly
from them; they show themselves in manifestations
differentiated
which one is inclined to designate as verbigerations, stereotypes, and
echopraxias.
Course. As a rule paresis results in death within a few years.
The few so-called cures, which are mentioned in the literature of the
subject, are doubtful(wrong diagnoses? long remissions?). In rare
exceptional cases a remissionmay last a decade or even longer and
even without a plain remission a case may be drawn out for many
years. That is so rare, however, that it should not be considered.
The galloping form may result in death after an excitement lasting
eight days.
The onset probably always gradual, even in the case where an
is
acute attack makes the disease manifest to those around it.

first
Pupillary disturbances as well as transformations of character in many

cases can be shown to have taken place a decade before the actual
outbreak and symptoms like those of neurasthenia may for a few years
exclusively announce the severe disease.
But when the paresis is once noticeable, extensive remissions may
simulate a cure. This hardly ever occurs in the simple demented

form.
The different manifestations may appear in an entirely irregular
sequence. In the prodromal stage, i.e. before the disease is recognized,
pupillary disturbances and those of writing, and transformations of
character, are most frequent. A neurasthenic symptom, a paralytic
attack, or another physical sign may begin the action just as well as
a pronounced psychic syndrome, e.g. a senseless or criminal act. For
the later stages, too, no rules can be set up, except perhaps that the
excitements in severe dementia naturally readily assume the character

of confusion.
As the most frequent premonitory symptoms should be mentioned
the pupillary disturbances and in complication with tabes the absence
of the patella reflex, then irritability, anxiety, excessive ambitions or,
the reverse, unusual weakness of will, twilight states lasting for
minutes or hours, very similar in appearance to the epileptic, often
with some incorrect act, attacks of dizziness, fainting spells, transient
double vision, temporary failure of speech, sleep disturbances and
especially the neurasthenic syndrome.
The same in the different forms; non-
last stage is essentially the
essential differences are brought about by the affectivity (euphoric in
most cases, depressive or indifferent in others), and by the existence or
absence of erethic conditions. The individual morbid pictures will
be discussed below.
Death results in the uncomplicated cases from marasmus with or
without pneumonia. Paralysis of the bladder and decubitus give
occasion for infections of all sorts. Paralysis of the muscles of swal-
lowing and respiration may produce pneumonia and choking.
Paralytic attacks may also prove fatal. Many patients come to grief
because of their motor or psychic deficiencies; suicides occur in the
depressive, more rarely in the simple forms.
The duration of paresis is difficult to determine. The better the
anamnesis the further it can be dated back, not so seldom to a decade
before the manifest outbreak. From this period on the disease lasts,
on the average, about three years; the shortest course runs in the
agitated forms. In all forms, except the agitated, single cases may
be protracted over a very long period; the maximum noted so far
in one case is thirty-two years.
Grouping. To present the different clinical pictures of paresis,
four main types have been differentiated into which most cases can
be classed. But there are continuous transitions from one form to
another. The individual case, however, remains usually, not unex-
^ ceptionally, within the type of the form it has once assumed.
In the simple demented form, stronger exaltations and depres-
1.
sions, delusions, and confused states are lacking. On the other hand
besides the typical organic dementia it exhibits as a rule the different
physical symptoms, especially attacks. For self-evident reasons it is
usually recognized rather late. At first not much else is noticed than
that the patients very gradually decline in their occupation the
simpler this is the later it is seen, then they become more and more
demented, awkward, and weaker.
2. The manic or expansive form, also called the classical form,
because it was the type recognized, often becomes manifest
first
through a very acute manic attack with a feeling of intense joy and
power, flight of ideas, enormous impulse to activity in which the most
senseless delusions of grandeur betray the deep seated disturbance
of intelligence. The patient is not only God, but possibly a super
God, he possesses and with millions of ships as large as Lake
trillions,
Superior, he constantly brings home diamonds from India, hunts on

the moon, has invented a bicycle, with which in three minutes one
can ride over land and sea around the earth, etc. He is a general,
salutes everybody at the railway station and whoever does not respond
to the salute he wants to have shot. Paretic women are the most
beautiful that were ever on earth, all human beings are their own chil-
dren whom God brings forth every second from their womb. The
imagination does not always reach so far, and in the later stages of
dementia the evaluation of the possession sometimes takes the place
of its magnitude: The patient boasts that every month he kills five
or six pigs; he can lift a half a hundred weight; he tells that he has
inherited a dollar or that he has a fine hat at home, with the same
satisfaction asif he owned the earth.
Delusions of grandeur, pressure activity, and lack of critical atti-

tude are often expressed in inventions which are usually colossal non-
sense. At times, however, something less stupid may result. Thus
a man suffering from paresis invented a mixture to freshen up high
hats temporarily and supported himself with it for two years after
he had become useless for other work. Another speculated on the
rise of cotton prices while a fall was generally expected and won
nearly half a million francs.
3. The melancholic or depressive form usually begins less acutely;
the fluctuations also are rarely so great. The patients usually never
come out of their depression. The delusions are just as senseless but
take the form of ideas of impoverishment, of sin, and especially of
the hypochondriacal and nihilistic types.
4. The rather rare agitated form is defined in various ways. I
should like to include here only those cases in which one sees violent
motor excitements with confusion and failure to recognize the environ-
ment, without a manic condition; in addition hallucinations and
illusions of hearing and vision invariably occur. Furthermore one
also finds coarse cerebral irritating manifestations such as gnashing
of teeth, convulsive movements, later carphologia. The disease thus
runs a course resembling the picture of the old "acute delirium"; the
patients exhaust themselves after a week or more and therefore usually
succumb during the first attack. In milder cases the disease drags
along for months and in very mild cases remissions may even occur.
Other observers designate also as agitated those cases of manic
paresis which show marked excitement and rapidly succumb to ex-
haustion, cases which, corresponding with the virulence of the morbid
process, show more confusion and agitation than mania and pressure
activity. From the two forms described those that run a rapid fatal
course, from one to a few weeks, are distinguished as galloping paresu.
In the common classification one does not find euphoric paresis
which, though showing a persistently exalted mood with some
grandiose ideas, never reaches to the height of a manic condition. To
be sure, it may
be regarded as an intermediate form between simple
and manic paresis into both of which it extends without limits but
because it is the most frequent form, at least with us, I should like
to emphasize it particularly.
Of the related forms one should mention the cyclic, in which manic
and melancholy states alternate for a time with or without intervals
of an indifferent mood. It is very rare.
Many cases, which later are to be classed mostly with the depres-
sive,somewhat less often with the simple form, are conspicuous be-
cause of an extended incipient stage, closely resembling neurasthenia
and frequently mistakenfor it. If the nervous symptoms are perma-
nently prominent, sometimes called neurasthenic paresis.
it is
A paranoid form is rarely met which for several years impresses

one as paranoia and only then takes the usual course. The picture
may also be complicated by depressive moods and corresponding
delusions,
Tabo-paresis is the designation for the rather frequent association
of paresis with tabes; it is supposed to be peculiar also in the entire
combination of the paretic symptoms, in so far as it runs a slow course

with less pronounced real paretic manifestations.
A catatonic variety has also been distinguished but it is still an
open question on what the addition of catatonic or apparently cata-
tonic symptoms is based (the occurrence of paresis in a case of schizo-
phrenia or in a schizophrenic disposition?).
Some which in other respects are different, incline to stupor
cases,
lasting weeks or years. Here it is possible occasionally, but
for
not always, to prove a complication with a previously existing
schizophrenia.
Morbid Picture of the Manic Form. In individual but rare cases,
occulo-motor paralyses, pupillary rigidity to light, diminution of the
tendon reflexes precede the acute outbreak several years. The ocular
paralysis can usually be cured by antisyphilitic treatment; but the
other symptoms improve less often. These cases then have a pause
of several years after which the real onset does not differ from the
usual outline that follows.
A man, mentally and physically robust, begins now and then to
complain of "nervous" symptoms; a little headache or head pressure
or fatigue, either general or locahzed, e.g. in the eyes; his sleep be-
comes irregular. This is considered natural and is ascribed to over-

work. Treatments at times seem to bring about a temporary improve-
ment, sometimes none; a review of the history extending over longer
periods would show that the uncomfortable condition gets rather worse,
and the ability to work decreases. Topalgias or any other pains,
which are interpreted and treated as nervous or rheumatic, are some-
times quite prominent.
At the same time, or even a few years earlier there begins in
many cases a very gradual transformation of character that is so
stealthy that it is usually overlooked. The careful head of a family
now and then seems selfish or careless in a particular act, perhaps,
contrary to his previous disposition, he engages in a careless business
transaction or without sufficient reason he at times does not feel like
going to work.
An able country doctor gives up his practice he wants to be a sur-
;
geon and enters a clinic as an assistant but fails in spite of other good
qualities because he does not learn to control asepsis sufficiently. Then
he buys a second house and arranges it as a sanitarium that prospers
for a few years. Another physician begins enthusiastically and with
great success to carry on abstinence propaganda, but then leaves
everj'thing to become the head of a cooperative private institution
with a doubtful future. Both physicians after a few years are stricken
with pronounced manic paresis.
Later in the disease intellectual disturbances become plainer, even
though in the incipient stage they are rarely noticed and still less con-
sidered morbid. The physician who took over the new institution
once figured in all seriousness that he need only prescribe double the
length of stay in the sanatorium to his patients, then he would have
twice as many inmates, and this he did several years before the dis-
ease became manifest; later he was still capable of picking up in a
clinic a considerable knowledge of psychiatry and of establishing a
thriving city practice.
Intelligent relatives are first conscious of the increasing lability of
the feelings, at times in the sense of irritability, at times rather in the
sense of sanguine temperament with emotional flights, up and down.
Shortly before the outbreak one notices trespasses against good morals;
the patient begins to cheat at cards or he becomes sexually ofTcnsive
or commits crimes.
There is reason to suppose that such prodromal symptoms arc
not lacking in any case; but they are not always noticed. In mont
cases the acute manifestation usually surprises the family.
Within a few weeks, often even within a few days, a manic condi-
mood, tireless
tion attains its highest point with flight of ideas, exalted
pressure activity, and flourishing delusions of grandeur. The patient
feels capable of anything, undertakes senseless transactions, makes
inventions, becomes engaged to three women at the same time, for
whom he bought three identical brooches with stones made, in order

to send them to all three on the same day. Whoever hinders him is
brutally treated as an enemy; it comes to noisy scenes, peace and
decency are violated, and then the patient is quickly taken to an insti-
tution. Here right at the beginning one often finds, in mild or pro-
nounced form, the symptoms referring to speech, pupils, and hypalgesia
of the skin. The absence of critical faculty usually increases very
quickly, the patient is God, the President, or Pope he throws millions
;
around. Thus a chemist discovered the fourth dimension: "right left,

two dimensions, front rear, two more, equals four, strange that the
world had to wait for me to find this egg of Columbus."
Such patients are restless day and night; they tear up things, rattle,
sing, and scold.
After a few months the manic condition usually dies down and gives
way to a quiet euphoria. The physical symptoms also may subside,
in rare cases to complete disappearance. The patient now considers
himself cured, he has a certain insight concerning his excitement, and
corrects the worst delusions but considers the attack not so severe, or
as the self-evident result of confinement, etc. In some cases, which
are described as rareties, he may for a few years regain complete
capacity for work. Usually, however, he is more or less markedly re-
duced, affectively too labile and uncritical, but, in spite of this, he

may be considered healthy by his relatives. And herein lies a great
danger. If he has not ruined his fortune at the beginning of the attack,
he is now in danger of doing so. IMoreover it is sometimes noticeable
that he does not observe the rules of social intercourse; he may go
to sleep at a gathering and pass the matter by with indifference.
The remission usually lasts a greater number of months then there ;
sometimes follows a manic condition similar to the first, more fre-
quently a milder excitement with increased dementia. This game may

be repeated several times. A number of delusions are retained and
jjvv. '..'.. i-^.' .

''".' ^.. ^j,;*;: l-'-r.-;'''
Si;.-:-
->.;'....;. -.S v ^
./* ;V..--.' ' .- -M ,./
Fig. 4. Cortex in paresis. Cells stained. Disturbance of the layers. Thicken-

ing of the pia. Enlargement of many vessels. Infiltration of small cells into
the pia and walls of blood vessels.
;
produced at every opportunity, even during the remission: "Tomorrow

I dine witli the President." In many cases such ideas are produced
in ever increasing numbers and in even more senseless quality, and
are mingled with the products of confabulation. Educated patients
endeavor at the same time to retain their bearing; but they do not
succeed in every respect; they easily become filthy, and lose their
self-control. With or without external causes excitements arise; if
the physician, as is often the case, must refuse the patient some-
thing, the latter promises to have his head cut off; he summons a
regiment, a billion soldiers, who will shoot down the physician and
the institution and the entire city. But very soon he is friendly and
happy again. Excitements from within usually last longer, sometimes
weeks or months.
In the meantime paretic attacks may occur from which the patient
mostly recovers very well.
As times goes on, the weakness of judgment and lack of critical
faculty becomes more marked, new material is less and less produced
the patient still repeats in a stereotype fashion his old ideas ; he indus-
and becomes unclear in all respects.
triously gathers all sorts of refuse,
He becomes entirely incapable of comprehending the environment;
he does not know where he is, and what happens about him. Even
without aphasic disturbances it ultimately becomes impossible for
him to comprehend even the simplest requests, let alone comply with
them. The physical symptoms take the upper hand, his speech be-
comes a hardly comprehensible babble, his helplessness in all respects
becomes worse, the patient has to be kept in bed more and more, he
cannot attend to any of his needs himself, he becomes unclean, partly
from psychical indifference, in part from paralysis of the sphincter
muscles or from incontinentia paradoxa. He chokes easily, or in great
gluttony he shoves in so much food that the mouth cavity and throat
are completely stuffed.
The is mostly noticeably good for a long time,
state of nutrition
often until death. In some cases marasmus occurs during the final
stage; and in rare cases it is followed by marked obesity. The end
finally results from an attack, a simple cortical paralysis, a terminal
pneumonia, decubitus with infection, or a fracture resulting from
the osteoporotic bones; in the majority of cases death comes without
the patient being conscious of his misery and without the disappear-
ance of his euphoria.
Morbid Picture of the Depressive Form. Many of these patient-s,
simply because they are timid, exhibit the "nervous symptoms" at an
early stage and to a marked degree. Such patients are frequently
treated for several years as neurasthenics. Ultimately, however, one

notices the decline of the ordinary psychic functions, or the paretic
physical symptoms. The depression becomes worse, coming either
in attacks or progressing gradually; it is usually connected with
anxiety. An
attempt at suicide often brings the patient into the in-
stitution. There he is terribly unhappy, he feels that he has com-
mitted every sin, he is punished in an appalling manner here on earth
as well as in the hereafter, the world has come to an end or has never
existed, his entrails have been consumed, and his limbs are wooden;
"I have large legs, I no longer have any legs, I do not exist." Some
Paresis.
Fig. 6. Gliosis at the cortical edge and around a smaller blood vessel.
bear their fate with a certain outward calm and remain in bed, others
run about, cling to everything, push away, scream incessantly, until
death relieves them.
The picture of simple paresis is more monotonous. With or with-
out nervous symptoms, often slowly in the course of several years,
often more rapidly in a few wêeks, the patient fails in his work and
in his social conduct. He becomes flighty and careless, forgets to pay
his club bills or gets served without having any money. He becomes
selfish, with his clothes, although he neglects himself,
dissatisfied
scolds if everything is not according to his wishes, buys four umbrellas
at once without knowing why, or cannot find his way in the city. The
cook puts too much salt into the food or none at all, or pours petroleum
on the salad and puts sugar into the soup; later she throws into one
pan "everything that is in the larder." The wife knits stockings of
senseless shape and size. A woman patient brought into the institu-
tion five pounds of cigar butts in her coat pockets. Aside from this,
the mental and physical basic symptoms gradually become plain; the
latter often follow paralytic attacks which seem to be here particularly
frequent. The patient mistakes places, calls a seal a sleigh ride, etc.
Fig. 7. Paresis: Infiltration of round cells into a cortical blood vessel.
Mild excitations are sometimes observed. The patients change

their vocation several times, they are little concerned with time and
custom, e.g. they get up in the middle of the night to take senseless
walks. Frequently they indulge in drinking and sexual excesses.
The simple demented paretics usually come to the institution in
a seriously reduced state. nothing acute that can become
As there is
regenerated, extensive remissions are very rare in these cases. Usually

they are entirely lacking and the mental and physical decline begins
pretty quickly.
The euphoric form most closely resembles the manic, only the
fluctuations in a good and a bad direction are lacking, or they -are
slighter, and especially never attain the height of a manic state. The
THE INDIVIDUAL MIONTAI. DI8EASKS 207
delusional productions arc also less and invariably have the identical
character as those in classic paresis.
Morbid picture of agitated paresis. The course of this form may
be illustrated by the following specific case.
A substantial baker hasbecome less reliable in the last twelve
years with
; unfortunate inventions and speculations he has squandered
a neat little fortune. Suddenly he becomes more restless, stays away
from home very often, though to be sure he gives definite excuses, he
no longer wants to tend his oven himself, etc. Several months later a
hallucinatory delirium breaks out very suddenly, voices command him
to undress completely, to partake of only three mouth fuls of food at
each meal, and to cut off Brought into the insti-
three of his fingers.
tution, he throws together everything he lays hands on, pours the soup
into the plate and back into the bowl and then again into the plate
until everything is on the floor day and night he pounds on the doors,
;
tears things up, jumps around, attacks the attendants in a brutal way,
fails to recognize his surroundings, and does not permit his attention
to be held in any way. His talks appear entirely incoherent. Be-

sides he has the physical signs of paresis. After about a week he is
completely exhausted, permits himself to be kept in bed, at first with

the aid of hypnotics, but he is still in incessant motion, which in the
meantime quickly appears weaker and less systematic and after
another week he dies from exhaustion.
Anatomical Findings. In paresis the nervous elements of the brain,
and often those of the spinal cord also gradually disintegrate, and
to be sure in different ways, without anything in common to the de-
structive processes being known. The arrangement of the ganglia
cells in rows and layers seems disturbed. The glia grows profusely
in the cells and fibres and in such a manner that these elements seem
to be increased and enlarged, that is to say thickened. This increase
can readily be differentiated, even on superficial examination, from
the increase of the glia in senile forms, by the degree of the increase,
and specially by the marked thickening of the elements. INIitoses of
the glia cells are not rare. The sheaths of the smaller vessels of
the cortex and pia (and even of other organs) are infiltrated with
round cells, which usually show the character of plasma cells. This
latter finding is said to be characteristic of paresis, as it only is met
elsewhere in the African sleeping sickness and, according to v. Mona-
kow, in multiple sclerosis. Other frequent alterations of the vessels of
an atheromatous or other degenerative character are probably com-
plications. The formation of new capillaries is often plainly observed.
In the tissues are sometimes found the red cells described by Nissl,
"very elongated, uncommonly narrow formations, at times curved,
which consist almost only of a single bright nucleus with several
nucleolar bodies, beyond which the body of the cell extends at both
ends, sometimes more and sometimes less." Their significance is not
yet evident. Lately spirochites have been demonstrated in the central
organs by Noguchi and others.
Macroscopically the brain is diminished, in very old cases to less
than 1000 g., the surface has frequently lost its smoothness as a result
of an atrophying process; the convolutions are narrowed, and the
fissures widened. The white substance is of a dirty discoloration and
often contracts in the plane of incision, if its severer atrophy is not
concealed by (Edema of the brain. It is striking that for the clinical
focal manifestations an anatomical substratum is not always found.
But sometimes it is a case of Lissauer's paresis, in which very acute
shifts with violent cerebral manifestations have affected circumscribed,
regions, especially in the occipital region.
The findings in the pia do not stand in a definite relation to those
of the brain. But the usual findings are as follows The pia is thick-
:
ened and opaque; it often shows adhesions, sometimes to the cortex,

so that in peeling it, parts of the upper cortical layers come off
(decortication),and sometimes to the adjacent folds so that one can
only go through the median fissure or the fossa Sylvii with the help
of a knife. Microscopically one observes an increase of the pia tissues,
round cell infiltration (especially plasma cells) and the identical
changes in the small vessels as in the cortex.
Nowhere is Pachymeningitis haemorrhagica found so frequently as
in paresis, and often the dura adheres to the skull. A certain weight
has been attached to the fact that the diploe is frequently lacking.
Naturally the spinal cord shows secondary degenerations as a re-
sult of the changes in the brain, but very often there are primary
alterations similar to those in the brain.
The peripheral nervous system sometimes shows chronic degenera-
tions. The aorta is mostly luetically altered. The other organs also,
above all, the liver, are usually not normal; but more definite char-
acteristics are still lacking. The ordinary manifestations of lues and
their remnants areremarkably rare (except in the vessels) in paretics.
Causes. The disease which is now differentiated from the other
organic psychoses as paresis is in the same sense as tabes, a "meta-
syphilitic" disease, i.e. at the present time it is a late manifestation
of lues, hardly ever associated with ordinary luetic symptomg, and
uninfluenced by antiluctic treatment. According to statistics of army
officers about 4 percent of syphilitics are afflicted later with paresis.
Severe or mild, thoroughly or superficially treated syphilis may be

followed by paresis.It is not, however, without reason that some speak
of a special "lues nervosa" which is said to run an easy course and to
dispose one to tabes or paresis. supposed to be transmitted as
It is
such with its peculiarity. However, paresis
in married couples is not
so frequent that the element of chance be excluded; it is more likely
that cases of paresis with a common source of infection favor this
conception. Since tertiary manifestations are practically never found
in people having paresis, and as secondary symptoms of lues, also,
are infrequently noticed in the anamneses, it may be assumed that
the mild forms of lues are especially predisposed to paresis. But it
may be that the tertiary and the metasyphilitic symptoms are mutually
exclusive. At all events it is striking that in marital infection from
Fig. 8. Paresis. Plasma cells on the wall of a capillary.
a paretic the lues is latent much more frequently than is otherwise the
case. What the personal predisposition to this kind of brain lues is,
no one knows; that paresis is the psychosis of the healthy brain has
been supposed with just as little reason as that it appears only in
cases of psychopathic heredity. However, in the previous history of
many paretics a very unsteady manner of living is found, and Savage
once called attention to the fact that the}- have mostly taken wives
of a markedly sexual type. Where this type is the exception as in
Switzerland, this can be confirmed. Reichardt claims to have demon-
strated a small cranial capacity as very frequent in paresis.
That mental exertion is an important factor has not been proven.
But it is probable that alcoholism plays an important part among
those predisposed, because paresis is extremely rare among those who
have been total abstainers from youth. On the other hand there is
a racial predisposition which we do not as yet understand. Among
.

the natives of the Balkan States it is rare; among African Arabs,
Abyssinians and Australian negroes it seems practically never to occur;

with the Japanese it is said to have become more frequent only in
the last decades; with the negroes of North America it was formerly
rarer, now it is especially frequent. It is much rarer in rural dis-
tricts than in cities. The deciding factor, therefore, is probably not
the race as such, but the manner of living or some added determining
cause, e.g. a second infection of a different sort.
As precipitating or secondary causes one names mental exertions,
heat, traumata, and other influences, but none of these assumptions
have even been confirmed. The various injurious consequences of the
war have, as far as known, conditioned no noticeable increase of
paresis. Nevertheless injury in the service, be it in the sense of
causation (precipitation) or in the sense of merely aggravating the
disease, was assumed after over-exertions, head trauma, infectious
diseases, etc. Scientific proofs of such connections are still lacking."
Paresis appears most frequently from about eight to twenty years
after the syphilitic infection; but there are also belated cases and those
that become manifest after a fewer number of years (up to two years)
The disease, therefore, occurs in the period of most active endeavor,
after the man has established a family (maximum between 35 and 45)
and thereby attains an especially great social significance. To be
sure there are cases of infantile paresis, that are based on hereditary
lues and that mostly run a course following the type of the simple
demented form. In contradistinction to many other manifestations
of hereditary lues they break out mostly after the sixth year, indeed
in some cases not until around the age of twenty.
In accordance with its nature the male sex is much more fre-
quently afflicted than the female, but the morbidity of the latter is
rapidly increasing, especially in the large cities, where the proportion
is one to two, while the average proportion may be still about one to
four. Men are afflicted relatively more in the upper classes, while
women in the lower. Cases of infantile paresis are naturally equally
divided between two sexes.
Pathology. The finding of spirochites in the brain tissues and
of plasma cells in the walls of the vessels shows that it is a question
of a direct manifestation of lues in the brain. Whether it is a par-
ticular species of spirochites, an inherited predisposition of the patient,
" Compare especially Bonnlioffer, Die Dienstbesehadigungsfrage in der Psy-

chopathologie. Die Militariirztliche Sachverstandigentatigkeit auf dem Gebiet
des Ersatzwesens. Vortrage redigiert von Adam.
. . . Vol. 1. Fischer, Jena
1917, p. 86.
or later additional infiucnocs that make a case of parcsiH out of a

case of lues is not known. Racial dispositions may be variously in-
terpreted; that paretics are somewhat more burdened with psychoses
and neuroses than the normal, even though less burdened than the
insane, and that they themselves, for the most part, had something
psychopathic about them even before, seems to point to endogenous
influences; on the other hand, the additional effects of alcohol point
to exogenous. It is interesting that cases of paresis from manic de-
pressive families have a particular inclination to the affective forms,
while those with schizophrenic relatives get, by preference, paresis
colored in the sense of schizophrenia. Besides alcohol we do not know
any contributing causes that are favoring or necessary to the origin
of the disease.
Diagnosis. In the prodromal stage it is necessary to seek the
premonitory symptoms enumerated above,^* among w^hich migrain
with or without scintillating scotoma may be mentioned when it has
rather suddenly appeared in the critical age, and is not inherited;
furthermore all premonitory symptoms of tabes, such as the crisis
and above all pains of uncertain origin falsely interpreted as rheumatic.

The organic disease is confirmed by the affective state and the
associations, the dementia by the lack of critical faculty and the
kind of delusions, and the paresis in particular by the somatic
symptoms.
The diagnostic significance of the individual psychic sj'mptoms
may be inferred from what has been said. Prodromal violations of
ethical principlesby people formerly decent are perhaps the only
ones that should be particularly mentioned here.
The physical symptoms without certain proof of an existing mental
disease can in themselves be generally decisive. Paresis has the char-
acteristic pupillary disturbance in common with the other luetic
psychoses and tabes; encephalitis lethargica also at times leaves pupils
that are irresponsive to light. Unequal pupils occur persistently in
normal people, then also in catatonia, but they usually change quickly,
while in paresis they change at the most in the course of weeks and
months. Sluggishly reacting, or rigid pupils are often found in the
alcoholic psychoses with an organic element, very rarely in the hysteric
with contraction of sphincters, then in the epileptic in the course of
the attack, etc. One must hear the paretic speech disturbance but after
that, one very rarely mistakes it. The stuttering of imbeciles is some-
thing entirely different; here the sounds may be inexact but they are
not misplaced and are not run together; on the contrary they are
" Cf. D. 257.
combined less than in skilled speech. The dysarthritic disturbances of
other organic brain diseases have not yet been sufficiently described,
even though they are in most cases easily differentiated from those of
paresis. One has to think only of the hesitating and singing of epileptic
speech to recognize it when it is developed. Yet slightly developed
speech disturbances in paresis and epilepsy can have a certain
similarity.
The speech disturbance must often be looked for. For this purpose
one finds useful some test words which make a great demand on co-
ordination: Above all "Third riding artillery brigade," or "Elec-
tricity," or "Methodist Episcopal Church," where the patient usually
gets stuck on the p and s sounds, or "Around the rugged rock the
ragged rascal ran." Such long test words as "Constantinopolitan
ladies" are not as good as those cited, and test more the psychic
qualities like attention and correct reproduction, than coordination.
One must particularly learn to distinguish between psychic and speech
errors. He who instead of "Third riding artillery brigade" repeats
without coordinating disturbances "third artillery brigade" is, to be
sure, usually an organic case but seldom a paretic. Furthermore, it
must be considered that many patients by strained attention succeed
even with difficult words, while in ordinary conversation they fall
down on more simple ones; or the paretic, who has been examined by
several physicians in succession, is specially practiced in the test
words and, therefore, reproduces them particularly well. On the
other hand anxious attention may in itself cause the downfall even
of those not suffering from paresis in the speech stunts of the tests.
In many cases this danger may be circumvented by permitting the
patient to read something aloud, and this can be done with better
results when the patient is not aware that his speech is tested.
The handwriting cannot always be evaluated because it is changed
in a similar manner by other diseases, and the results of severe trem-
bling are sometimes difficult to distinguish from those of disturbances
of coordination. But the examination of the handwriting need not
be dispensed with, and in cases where the diagnosis is definite the exam-
ination of previous handwritings is sometimes the safest means of
determining how long ago the disease began. Moreover, in an existing
psychosis it can at least present evidence of a cerebral affection, which
in most cases indirectly assures the existence of paresis. Neurasthenics
and other excited people, also, sometimes make mistakes in handwriting
both as to quality and quantity that are difficult to understand. But
they can easily correct them; on the other hand the person afflicted
with paresis leaves most of his errors uncorrected, he also cannot readily
find them and when he does make corrections they are very often
wrong.
Paralyses are also significant when it is certain that they have been
acquired wliich, e.g. in the case of facial inequalities, is not always
easily determined.
Paralytic attacks are often mistaken for apoplectic attacks but in
Apparently severe attacks
the latter the protracted twitchings arc rare.
with consequent paralyses and very rapid complete recover^' point to
paresis.
To be sure the easiest way to make the diagnosis at present is
through an examination of the cerebro spinal fluid. If pieocytoses,
Nonne and Wassermann, are found in an existing psychosis, the diag-
nosis is as good as settled. To be sure tabes can produce the identical
manifestation; but their existence only increases the probability of
paresis because with the rarity of "tabes psychoses" in the narrower
sense, a mental disease combined with tabes, is very probably paresis.
In some exceptional cases of paresis the Wassermann findings may at
times be negative for a shorter or longer period ; this is mostly the case
in stealthy or stationary stages or in very slowly progressing varieties.
Cave: In the secondary stage of syphilis one sometimes observes in
the cerebro spinal fluid the same findings as in paresis, but its only sig-
nificance is that it is a transient mild cooperation in the infection on
the part of the central nervous system and its integuments. Paresis
at this period is extremely rare.
The differential diagnosis of manic paresis from the manic attack
of manic depressive insanity rests on the demonstration of the physical
symptoms, also on a thoughtlessness and lack of regard in all actions
which are exaggeratedly out of proportion to the excitement, and
above all on the foolishness of the delusions. Mistaking individuals is
rather a trick with manic depressives; whereas paretics believe in
their fictions. But particular care must be taken in the case of initial
outbreaks during manhood, because paretic symptoms that are lacking
today may appear tomorrow. At anj' rate in a pronounced manic
state of paresis the delusions are nearly always present.
The differentiation from states of melancholia rests on the same
principles.
As against schizophrenia the diagnosis is often not easy, when we
have mere conditions of excitements with a senseless and confusional
trend of ideas which do not assume a distinct and specific form. Indi-
vidual catatonic signs, which under such circumstances usually cannot
be anaylzed, are not yet evidence of catatonia, but affective stiftness
and lack of intellectual and affective rapport, furnish such proof. Since
somany paretics were always pronounced psychopaths, the anamnesis
may often only confuse instead of enlighten. Here, as in all psycho-
pathies, it is often of decisive importance, if from a definite time a
change of the psychic attributes in the sense of paresis can be ascer-
tained or excluded.
As against epilepsy, only the specific signs of the two psychoses
can be decisive ; when epileptic attacks appear in middle age, they are
mostly not pronounced in any direction, and therefore there are cases
where for a time one wavers.
Because of the tendency of paretics to excesses the alcoholic forms
frequently give occasion for doubt. Korsakoff's disease as an organic
psychosis has the most important psychical symptoms in common with
paresis, but the neuritis and the lack of the specific paretic signs
(pupillary disturbances also occur there!) usually remove the diffi-
culties; sometimes the mode of onset of the disease also helps the
diagnosis. But the peripheral neuritis is not always present. Alcoholic
pseudo paresis causes still greater difficulties. I have never seen pro-
nounced delusions of grandeur accompany it, but it is said to occur in
rare cases. Progression during abstinence instead of gradual, and at
least partial, regression decides in time for paresis. To be sure the
examination of the spinal fluid is a quicker way.
Not at all seldom it is a delirium tremens that first brings the real
case of paresis into the institution. The former passes away, the latter
progresses.
The paranoid forms of dementia paralytica are very rare, sO' that
here I would like only to call attention to them; if the symptoms are
still barely pronounced, then for a time the differentiation from
paranoia or paranoid states can only be made by lumbar puncture.
The differential diagnosis from brain tumors is self-evident, only
it must be mentioned that there are slowly growing, infiltrating gliomas
which may run their course entirely under the picture of a simple
paresis with indicated local symptoms. Without a lumbar puncture
one can miss the diagnosis up to death, and it is just in the case of
suspected tumor that the puncture is dangerous.
From the remaining organic psychoses paresis can be certainly
differentiated only by the physical symptoms (including the fluid),
even though pronounced paretic grandiose delusions alone permit the
diagnosis without too great a risk.
To draw the boundary line between neurasthenia and paresis is one
of the most important problems. The complaints are frequently the
same for a long time. The neurasthenic supposes, e.g. that he is suffer-
ing from weakness of memory but when he is examined for it nothing
;
.
is found, or instead one sees affective memory difficulties; he fears he

is from "softening of the brain" and thinks he has a speech
suffering
disturbance, but the hitter shows itself, when it is present at all, to be
graduated not according to the articulatory difficulties of the words,
but according to the momentary degree of anxiety. Especially im-
portant is the attitude of the patient toward these symptoms. The
neurasthenic pictures everything as more difficult than it is; he likes
to hear himself consoled but is not quieted immediately, or at all. The
paretic usually does not take matters so seriously; he very readily
offers excuses: Just at present he is somewhat tired or frightened by
the examination or he is chilly or anything similar. And when, in
depressive cases he really is anxious, he remains inconsistent and
readily neglects the physician's directions which the real neurasthenic
does only when he is bothered by several "Systems of Treatment."
Above all the neurasthenic shows an exaggerated self-observation and
is accustomed to attribute an exaggerated importance to the symptoms
while the paretic usually appears indifferent and exhibits a striking

incapacity for self-observation. This difference is also seen in the
depressive conditions with retained intelligence (e.g. in the manic
depressive states).
Treatment. Prophylaxis consists in the avoidance of, or combatting
syphilis and alcohol, the latter, because on the one hand it increases
the chances of infection, on the other hand because it helps lues to
develop into paresis. It has not been proven that the energetic treat-
ment of erupted syphilis betters the chances against later affliction
with paresis. It is not a rare technical blunder to prophesy the
approaching paresis (or tabes) to patients with pupillary rigidity or
absent patellar reflexes. If later difficulties are to be anticipatedj a
responsible person should always be informed of the possibility of
the future outbreak of such a disease; the patient himself, who breaks
down anyway at the critical moment, should be spared and, when
possible, his wife also.
The treatment of pronounced paresis as a disease has so far been
hopeless. Antisyphilitic treatment as well as salvarsan are ineffective.
Very recently successes have been reported from the infection of
patients with tertian plasmodium (Wagner v. Jauregg)
An early diagnosis is most important, in part to save the expense
of ruinous and useless treatments, in part to secure the existing estate.
When cases of paresis come into hospitals, they have, in great part,
impaired their estate severely as a result of their grandiose delusions
or of the dementia. It is the duty of the family physician to
instigate the necessary steps in time. Above all there is danger in
the long remissions upon which judges and relatives like to look as a
cure, whereas the existing feeble-mindedness and the euphoric mood
as well as new shifts impair the patient's capacity for independent
action.
The obvious general rules of treatment should be followed in the
excitements as well as in the stage of helplessness. In anxiety states
opiates often render good service. Careful oversight of the bladder is
essential, as otherwise paradoxical incontinences remain concealed and
may lead to paralysis or rupture of the bladder. Many patients can
under favorable circumstances be treated at home as soon as it is
certain that they will permit themselves to be managed, and will not
endanger their estate or compromise themselves by sexual excesses
or criminal acts.
In paralytic attacks a simple conservative attitude is best; the
patients are protected from harm through collision and rubbing, but
above all against uncleanliness. Artificial feeding is resorted to only
in cases of necessity; the patient will not die at once from inanition
but with these helpless patients the danger is especially great that
some of the liquid food is inhaled into the lungs when the tube is taken
out or when they gag. Nutritive enemas are often not retained. When
necessary an infusion of a physiological salt solution beneath the skin
can at least maintain the supply of water at the proper level. If the
relatives demand "that something be done," ice-packs applied to the
head are advisable, and amylenehydrate or paraldehyde or chloral-
amide are said to reduce sometimes the violence of the convulsion.
The first two drugs can also be given as an enema in a vehicle that
protects the bowel (chloralamide 4.0 to 6.0 (!), Amyli 4.0, Ap. dest.
150.0; or Amylenehydrate 4.0 to 6.0 Aq. dest. 60.0, Mucil Gummi arab.
30.0 for enema). Heart stimulants are also given, when a collapse is
threatened.
But I do not have the impression that the attack runs
its course the worse in any respect whatever, if the patient is not
bothered at all.
V. SENILE AND PRESENILE INSANITY (SENILE

PSYCHOSES)
Under the name of senile psychoses Kraepelin includes the presenile
and senile mental disturbances, among the latter separating arterio-
sclerotic insanity from senile dementia with which he also classes
presbyophrenia.
The presenile forms are as yet symptomologically as well as sys-
tematically entirely obscure. It has not even been definitely proven
that there are such forms. No doubt certain forms are favored at the
period of involution since, c.^,. depressions and anxiety states increase
greatly from this time on and it is possible that certain psychoses still
occur in this period. The morbid pictures here considered as presenile

are with difficulty separated from the senile forms, in part because a
few of them also evince an organic character, in part because naturally
in case of a protracted duration a senile brain alteration may very
easily be added to the presenile, in which case the furtive development
of the organic symptom for a long time easily conceals the fact that
something new has stepped in.
The conception of "Involution" which is infused with the idea of
"presenility," is sometimes conceived in the sense of a regression that
ends with death, sometimes in the sense of transition to a new age,
similar to the "climacterium": The designation "Involutionary Psy-
choses" isbased on the latter conception, directing attention to a
difference as opposed to the senile psychoses.
The actual senile (psychoses, that we know, all have a definite
tendency to progress, or expressed anatomically, to the gradual destruc-
tion of the brain. That there are not also curable psychoses belonging
to senility,is naturally not excluded as yet. But with these I should
not like to class "senile melancholias" with mild organic features or
organic confusions and deliria, because on closer examination it is
always found that after the disappearance of the striking symptoms
the patientis, in the sense of dementia senilis, a weakened individual.
Therefore, I conceive such storms as intercurrent manifestations of a

senile brain degeneration, just as in pronounced senile dementia and
analogous to the acute appearances in paresis and schizophrenia, and
theoretically I place the major disease in the foreground, even though
there are cases where the restoration of equilibrium has practically
the significance of a cure. On the other hand Kracpelin usually places
the practical result in the foreground and designates many senile
melancholias with nihilistic delusions or other organic manifestations
as curable, as long as the psyche is not as yet materially damaged
otherwise.
Furthermore other psychoses, like manic depressive shifts, which
also oecur at this age, naturally do not belong to the senile; here the
disposition lies in the native constitution and not in the age.
The senile psychoses offer three different classes of anatomical
findings: arteriosclerosis with its effects on the nervous system
{arteriosclerotic insanity), simple atrophy of the brain {dementia
senilis in the narrower sense) and spherotrichia {Vcrdrusung') with or
'without alteration of the neuro-fibrils {presbyophrenia) . With the
;

first and last alteration there naturally also appears regularly sooner
or later a nutritive disturbance of the entire brain and besides, the
three processes can, from the beginning, be combined in all possible
combinations. We rarely have pure forms in practice.
The above all anatomically the diffuse reduction
essential thing is
of the brain substanceand symptomatologically the complex of the

"organic psychic" symptoms. The latter alone are present in the
simple senile forms. In arteriosclerotic insanity there are also neuro-
logical cerebral manifestations and the psychical defects for a long time
have something lacunar about them. In the presbyophrenic forms the
picture is complicated by excitation and some other symptoms.
The three senile forms have within the organic group a common
differential diagnosis, which, as against paresis, is decided chiefly by
the absence of the paretic signs (speech, pupils, fluid, blood Wasser-
mann) As against alcoholic Korsakoff the decisive points are the lack
.
of the signs of alcoholism and, up to a certain degree, neuritis. The

remaining organic diseases (brain tumor, multiple sclerosis, etc.) carry
which are wanting in the psychoses
their particular neurological signs
previously mentioned.
The alcoholic Korsakoff patient is as a rule euphoric in the begin-
ning but not manic as in classic paresis. The deeper moods of the
senile patients are in the great majority of a depressive type.
Organic depressions, especially senile, externally often closely
resemble late catatonias since they are rebuffing (like negativism),
mutistic, and have moods and fits (like the stereotype forms). The
general specific signs, especially memory defects, may still be absent
in the beginning. For purposes of recognition the good affective reac-
tions are especially of service, which, to be sure, may manifest them-
selves only in little noticeable movements of the corners of the mouth
then also the accumulation of organic delusions: a million years in
purgatory, the abdomen isa sewer, it is blown up like a baloon (^hile
in reality it is entirely empty and contracted). Such ideas are not
excluded in dementia prsecox but are very rare.
A number of therapeutic viewpoints also are common to the group.
Like paresis they jeopardize the fortune and the legal relations gen^
erally. Therefore in every individual case the question arises whether
a legal guardianship should be instituted.
Beware of the advice that the patient should give up the accustomed
occupation without a substitute, unless it is absolutely necessary.
Senility often becomes a disease only as a result of the sudden cessation
of the ordinary attractions of life.
Interning in an institution should be much less frequently recom-

mended and should be less often permitted to become protracted than

in a case of paresis. If a senile patient has a home, under ordinary
circumstances he should be able to remain there.
Only when acces.sory
symptoms (restlessness, confusion) or danger for himself and those
about him appear, when he is melancholic, when he handles light and
fire carelessly, leaves the gas jet open, is inclined to sexual attacks,
threatens his wife and children,then only should he be placed in an
institution. If the danger is past, it should be seen to it that he is
again brought into normal condition.

The nightly deliria which are very annoying to all concerned may
sometimes be overcome by hypnotics but not nearly in all cases.
Besides the ordinary remedies bromidia may be recommended here
which contains a happy combination of narcotics precisely for just
such cases. Its formula is a secret; how to compound it is stated
below.^^ But the remedy can be compounded in every drug store.
Only the preparation then looks cloudy and must be shaken. Ris
recommends for the "reversed daily program" (restlessness at night,
sleep during the day) that 0.03 opium be given evenings around eight
o'clock; after one or two weeks, sleep would occur at night, when the
remedy can be omitted until further needed. In severe cases two doses
(6 and 8 o'clock) should be given; a triple dose daily (4, 6 and 8
o'clock) should rarely be necessary.
Presenile Insanity
Under this name are described entirely different, insufficiently
classified and characterized pictures: 1. rare subacute cerebral degen-
erations which result in death or dementia often after a few months
of senseless delusions, delirium, usually anxiety conditions, and which
are to be classed with diseases of the brain. 2. more frequent 7nelan-
choly conditions of varying appearance, usually improving (see manic-
depressive insanity and climacterium virile) 3. prett}' frequent para-
:
noid and catatonia-like forms, the former passing more chronically, the
latter rather in shifts, but on the whole with a bad prognosis. A part
but not all of the third category are belated schizophrenias. According
to my experience, Kraepelin's presenile delusions especially belong to
dementia prsecox.
Arteriosclerotic Insanity
Arteriosclerotic insanity has verj^ manifold ways of manifesting
itself. Usually arteriosclerosis of the brain with different symptoms
"Ext. Cannab. Ind. Ext. Hyoscyami fluid, aa 0.5. Kal. bromat. Chloral-
hydrati aa 50.0. Aq. dest. ad 250.0.
.

is present before a psychosis can be mentioned. Very few cases gen-
erally reach the psychiatrist. Arteriosclerosis in itself does not con-
dition a psychosis happens when there is a diffuse reduction
; this only
of the brain substance (aside from transient delirious conditions and
the emotional disturbances from large brain lesions).
The neurologic cerebral symptoms consist of head pressure, head-
ache with marked fluctuations, dizziness, fainting spells, buzzing in the
and all possible
ears, scintillating before the eyes, eventually paralyses
focal symptoms such as hemiplegia, hemianopsia, and aphasic and
apractic disturbances etc. The latter manifestations of organic de-
terioration are in the beginning usually unstable and can regenerate
very decidedly (i.e. they need not be based on hemorrhage and
softenings)
In very many cases other symptoms also appear as a result of
arteriosclerotic changes in other organs, especially the kidneys and the
heart.
As long as the psychic symptoms do not dominate the picture, the
disease is also designated as "the nervous jorm of arteriosclerosis of
the hrain."
The psychic symptoms like the physical begin very insidiously and
come and go in the beginning. The patients often feel something
like a void in their mind, their initiative weakens, it becomes difficult
for them to rouse themselves to action. Their endurance is diminished,
the accustomed attention is trying to them, they tire much more
readily than they used to. These symptoms invariably have a painful
effect whereby the morbid picture is again made more serious. But
undoubtedly there also exists a primary tendency to depression and
to an anxious conception of experiences, often even to severe anxiety
conditions, which evidently are frequently the direct result of circula-
tory disturbances of the brain.
This stage may last for years without material aggravation. Never-
theless the affectivity usually becomes more labile in a certain sense;
emotional incontinence is plainly developed. The patient's interest
becomes narrowed and the tendency to depression inhibits somewhat
the emotional fluctuations; nevertheless it is evident how they can
react in all directions in the sense of irritability and psychic
pain, and in periods of improvement also in the sense of joy and
longing, and what is characteristic is the fact that they react even
to trifles.
Gradually disturbances of memory, especially for recent experi-

ences, become more pronounced, at first only on certain occasions, as
on seeking a name, etc. later it is more generally noticeable, but always
;
oscillating up and down. Confabulations may appear but are rarely

numerous.
As a result of many fluctuations in the course of many years the
picture may become more and more serious. Anxiety states lasting
for minutes or weeks can assume a delirious character with failure to
recognize the environment, dreadful delusions of being cut up, burnt,
buried alive, usually as punishment for sins. The patients struggle
for breath, yell, accuse themselves, strive to get away, and make brutal
attempts at suicide. In the intervals also there is a tendency to real
melancholia. The patients become less courageous, they are timid,

conceive everything as painful, and form depressive delusions,
especially also of a hypochrondriacal type.
Other delirious states are rather rare in the simple forms, but they
are all the more frequent in the apoplectic types.
Apperceptive ability and attention are only gradually changed in
the sense of the organic syndrome.
Orientation at first suffers only spasmodically and finally it is en-
tirely destroyed, the physical strength is impaired, the patients finally
remain bedridden and die of marasmus or of apoplectiform attacks.
Apoplectic Forms. Very often the entire disease has its origin in
the attacks or these chiefly determine its course. Here one deals with
hemorrhages as well as softenings. The first attack occurs after
arteriosclerotic prodromal stages of varying intensity and varying
duration, or also in people who were still entirely well, with the usual
symptoms of headache, irritabilities, dizziness, fainting, and conse-
quent general symptoms and focal manifestations, the latter remaining
or regenerating according to their location. Depending on the general
nutritive condition of the brain and perhaps also on the localization of
the focus, the psychical signs of diffuse brain atrophy can sooner or
later supervene. According to my experience, lesions especially in the
region of the pons seem to be deleterious, although at first they produce
the least change in the psyche (circulatory disturbances starting from
the vascular centre?). On many cases, however, the psyche remains
for years disturbed so little that the patients are properly regarded as
mentally sound. Only the affectivity is often plainly changed in these
cases also, and this change is in Often
the direction of lability.
immediately after the stroke the patients can be made to cry and even
to laugh much more readily than before. In many cases they feel this
as positively unpleasant; real compulsive laughing and compulsive
crying, i.e. mimetic expressions to which no real felt affect corresponds
qualitatively and quantitatively, is a rare local symptom emanating
from the thalamic region.
Otherwise dementia apoplectica is not materially different from
simple arteriosclerotic dementia without apoplectic strokes with which
it is connected by transitional forms with rare or frequent minor
attacks.
Both forms may be complicated by moods (nearly always depres-
sive), and especially by irregular, fluctuating anxiety-melancholic
states.
Invariably the personality with its strivings is maintained for a
relatively long period; even when the patients already appear decidedly
demented they are not much changed in the fundamental aims of their
will, only they no longer understand everything and they permit them-
selves to be dominated more by their affects. The symptoms of deteri-
oration also are ''lacunary," i.e. as to time and in respect to special
functions they are entirely irregular, present or absent in part; thus
good memory may be surprisingly present in complete helplessness of
may be evinced side by side
the ability to recall, and correct judgments
with completely narrowed ones. While in paresis, dementia senilis and
presbyophrenia, one can infer with great probability from the general
condition as to individual abilities, in this case it would be very
deceptive.
Individually the pictures are naturally very different according to
the location and diffusion of the lesion on the one side and according
to the intensity of the general cerebral atrophy on the other.
Concerning the course of all forms Kraepelin emphasizes the fact
that first, the decrease in the elasticity of the vessels produces troubles
in the adjustment of the blood apparatus to the momentary needs;
this adjustment is particularly infinitely graduated in the brain. This
naturally also impairs the capacity for functional adjustments and
consequently produces the exhaustion, the difficulties in doing things
and perhaps, also a part of the early affective disturbance. It, finally
produces wrong reactions of the vessels, sometimes surely local
paralyses of the vessels, which causes the transient local troubles and
many fluctuating general symptoms Later one observes an insufficient
blood supply of circumscribed regions which are ever increasing in
numbers, sometimes even embracing the entire brain (e.g. in sclerosis
the entire circulus Willisii) with the various consequent manifestations,
and in the third place the hemorrhages and softenings resulting from
the breaking of the arterial walls and the blocking of the lumina.
The outcome is death following organic dementia. The latter may
not occur when the course is shortened by apoplexies and other attacks.
The duration of the disease may vary from a few weeks to two decades.
Age. Arteriosclerotic insanity appears most frequently between
THE INDIVIDUAL MENTAL DISEASES 2H;i
the ages of 55 and 65 years. But cases occur even in the forties ; they
are mostly conditioned by a family predisposition.
Both sexes are about equally represented in the apoplectic disturb-
ances, in the other forms, according to Kraepelin, 7L5% affect men.
A functionally limited morbid picture is arteriosclerotic epilepsy,
which usualy appears very early in the various localizations of arterio-
sclerosis and sooner or later leads to dementia. It is said to occur
mainly in alcoholics.
Concerning the anatomy of arteriosclerotic insanity nothing can
really be added to what has been said. Most of the varieties of arterio-
sclerotic thickening through proliferation of the vascular cells, hyaline
degeneration, etc. are found in the most different distributions, and as
a result of these there is local destruction of the nerve tissue through
degeneration and a filling in of glia ("perivascular gliosis"), through
capillary and large hemorrhages, through softenings, and besides in
most cases there is a diffuse reduction of the brain substance as the
expression of a general metabolic disturbance. The sum of countless
small lesions can perhaps also have the same effect as a complete
diffuse disturbance. The entire brain is invariably atrophied at death ;
it is reduced on an average by about 150 g. The pia is often thickened

with connective tissue, but hardly infiltrated or adherent.
The etiology of arteriosclerosis is for the most part still obscure;
it is not only a disease of civilization; its traces are said to have been
found in prehistoric races. At all events the family disposition is of
importance. On the basis of experimental facts, tobacco has been
blamed very recently; alcohol for a long time. Furthermore the
attempt has been made to include among the causes of arteriosclerosis
a number of circumstances such as conscientiousness and dissipation,
overexertion and laziness, and many other things, but as yet without
sufficient proof. In the ordinary cases, where the Wassermann is nega-
tive lues probably plays no part; as yet we do not possess sufficient
knowledge to differentiate anatomically the ordinary arteriosclerosis
from the specific in all cases.
As precipitating causes debilitating diseases are to be mentioned,
as in simple dementia senilis; the brain, the blood supply of which
might just suffice under ordinar>^ circumstances; can then no longer
obtain nourishment and atrophies in toto or in certain places to such
an extent that the psychic symptoms break out. Stronger affects,
especially depressive ones, often induce the rapid appearance of the
arteriosclerotic syndrome; the connecting link is probably the inade-
quate regulation and adaptive insufficiency of the vessels.
Naturally in pronounced cases the diagnosis is relatively easy.
In the beginning it is based on the different neurological symptoms
with their characteristic change.
The hardening of the cerebral vessels is not always easy to diagnose.
More severe sclerosis of the arteries of the body offers a certain prob-
ability of similar changes in the brain; but the lattercan just as well
be free in the case of pronounced hardening in other organs, just as the
reverse occurs. Importance is properly attached to increase of blood
pressure, slow pulse, to its abnormal increase after slight exertions
(climbing on a chair or bending ten times), then especially to the
marked differences between systolic and diastolic pressure. The
normal figures (measured according to Recklinghausen) are minimum
pressure to 100 mm. Hg., maximum pressure 160 mm. Hg., resp. 140
and 220 cm. HsO.
From paresis which is sometimes combined with arteriosclerosis,
it can be differentiated by the absence of the physical signs of paresis,
especially pupillary rigidity which is never found here, negative

Wassermann in the blood and fluid, absence of pleocytosis and globulin
reaction in the fluid,^** absence of expansive delusions and excessive
euphoria. Manic states hardly occur in arteriosclerotic insanity.
Anatomically there need not be in paresis a thickening of the vessel
walls, while the infiltration with plasma cells is foreign to arterio-
sclerosis.
From dementia senilis and presbyophrenia it is differentiated par-
ticularly by the fluctuations in the course and by the presence of the
signs of arteriosclerosis. Heredity also sometimes offers differential
points. When there are no circumstances that favor cerebral atrophy
such as a manic-depressive constitution, congenital weakness of the
brain, alcoholism, and heart troubles, an age of less than sixty-five
years speaks against mere dementia senilis. But it is self-evident that
the various senile processes frequently take place together.
Senile dementia and, to a still higher degree, paresis alter the per-
sonality much and fundamentally than arteriosclerosis; the
earlier
entire functions of memory, of the critical faculty, etc. are damaged
in senile dementia and paresis while arteriosclerosis at least for a long
time manifests itself in a "Mosaic of individual symptoms."
From brain syphilis arteriosclerotic insanity is differentiated by
the absence of the neurological signs (eye troubles, etc.) and by the
serological signs of lues.
Because of our ignorance of the etiology we cannot
Treatment.
carry on much prophylaxis
against arteriosclerosis. It is undoubtedly
good to avoid tobacco and alcohol. Still, pronounced arteriosclerotic
^"Increase of albumin occurs, as it seems, but no globulin reaction.
insanity is in many cases a grateful object of treatment. Mild, slowly

progressing disturbances are often markedly improved and there is
also occasion to prove that this is not chance but really the result of
treatment.
It is very often possible to free the patients from all the p.sychic
and physical exertions that they cannot bear, that is, from those
burdens which according to experience aggravate their condition. If it
is not known what the patients can stand, it is necessary to try them
out carefully. Neither the psyche nor the heart should be overtaxed.
As far as possible the patients should be protected against affective
disturbances. If the heart does not respond it should be treated but
not without care (digitalin; once in a while perhaps strophantus, etc.:
sensible treatment with digitalis hardly increases the danger of

apoplexy). We have had good results with diuretin in small doses,
also
e.g. 0.5 three times a day.Anxiety states can also be combatted from
the psychical side with opiates or at the same time with heart remedies.
Very often, too, a bromide preparation, especially sedobrol, produces
calm; it can be combined very well with small doses of iodide. Iodide
is generally given and under certain circumstances it probably has a
certain effect on the arterial walls or, at any rate, on their regulation
and, as has been lately supposed, on the viscosity of blood also. At
present many are afraid of such big doses as 3.0 per day, and prefer
smaller doses, e.g. up to 0.5 per day. All drugs should be stopped after
a few weeks or months until there is a new indication for their reappli-
cation. For example, an iodide cure can perhaps be given once ever>'
year.
Proof is lacking that any of the usually recommended diets are
useful; excessive meat diet is said to be injurious. Lewandoivsky
claims to have observed benefits from a diet with little salt. At all
events the patient should guard against overfilling his stomach either
-^
with solid or liquid food. Stimulating substances as well as alcohol
should be avoided on principle.
The psychic treatment, which should calm the anxious patient with
consolations, is especially important.
But under all circumstances, as soon as the condition permits, the
attempt should be made to keep the patient busy. In the beginning
of the disease before employment has been given up, this usually suc-
ceeds without much difficulty by having the patient do a smaller
amount of his ordinary work. If this is not possible, other work must
be sought for him that holds his interest. Exercise in the open, adapted
"Total abstinence from alcohol is a condition sine qua nan in any treatment.
(Pilz, Wiener med. W.S. 1910, p. 626.)
-
286 , TEXTBOOK OF PSYCHIATRY

to the strength of the heart, is naturally to be recommended. In this
way fairly tolerable conditions are often obtained for many years.
Naturally this is also the case when the arteriosclerosis has been
complicated by an involutionary depression independent of it, which
heals in time of its own accord, after it has made the picture appear
too serious.
Strenuous measures, like hydrotherapeutic treatments, especially
thermal cures, are naturally to be avoided. To prevent apoplexy in
pronounced arteriosclerosis, everything is to be excluded that increases
the blood pressure or leads to a rush of blood to the head, especially
hot baths, excessive eating and drinking, etc. Experience shows that
a cerebral hemorrhage is occasionally connected with such influences;
but too much cannot be expected from these regulations.
In arteriosclerotic epilepsy besides bromides, iodide may also be
given. But it is usually an incurable disease.
In accidents following sudden cerebral diseases the family physi-
cian's most important psychiatric problem often is to obtain a clear
idea of the patient's mental condition; because he sometimes has to
decide his testimentary ability either for present purposes or later in
court as expert or witness. Care must be taken not to mistake aphasic
or paraphasic symptoms for confusion and
(including paragraphia)
dementia. In all cases where it would be a question as to the patient's
responsibility for his actions pains should be taken to get in contact
with the patient through the most various means of understanding.
Since wills frequently are attacked only after years have elapsed, pains
must not be spared to make exact notes of the case.
Senile Dementia (Simple Dementia Senilis)

Even though the normal regression of the brain begins in the early
fifties, it does not usually become plainly noticeable until the last
decade of the normal span of life. The earliest sign we meet with in
most cases
in many people even before the end of the sixth decade
is a certain inability to assimilate the new ideas of others. Such per-
sons become passively neophobic even though they are still capable
themselves of creating new combinations of ideas to a limited extent.
But after a while the entire ability to assimilate is weakened; the
old man is less and what goes on in the world; his
less interested in
thoughts, now egocentric, are withdrawn to the more personal necessi-
ties, both in emotional and intellectual relations. The feelings become
more labile, and react to trifles; more protracted moods readily occur.
In social intercourse some cases show a tendency to empty chatter,
others to torpid monosyllabism. Besides excessive suggestibility one
is struck by a stubborn intractablcness. Not only the impressibility

but the entire memory becomes poorer, at first for names and similar
effortswhich are otherwise also particularly difficult. The inability
to understand and recall new experiences, the relatively or absolutely
easier reproduction of the old memory material in connection with the
general trait that memory more
pictures of a pleasant character can be
readily revived than the unpleasant, makes them into laudatores tem-
poris acti. All psychic processes become more trying and slower, par-
ticularly in proportion to their complexity. That the capacity for
practical work declines under these conditions is self-evident.
Simple senile dementia is said to be a simple exaggeration of these
symptoms which in a mildly indicated or pronounced form are found
in nearly every person who attains his normal end through "weakness
of old age."
As the first morbid symptom there is often noticed a change of
character, sometimes at first in the sense of caricaturing personal
peculiarities; a sense of order develops into picayune pedantr}', firmness
into stupid stubbornness, care into distrust, economy into filthy stingi-
ness. Then as in paresis there comes the falsely so-called ethical
obtuseness which here also is a combined product of imperfect concep-
tion and elaboration of experiences and ideas and perhaps
; at the same
time there appears the lability of the affectivity with its heightened
negative and positive suggestibility: "The old man is a child." The
beginning of the disease sometimes marked by sexual excitation.
is
Men, who have long been impotent, "feel young again" and under
certain conditions actually perpetrate excesses. Others remain more or
less impotent but the libido is enhanced.
Then the memory fails more and more and just in simple senile
dementia this often occurs in an entirely systematic manner; the more
recent an experience, the sooner it is forgotten; (usually it is still
"noticed"; but is capable of being recalled only for a short time). At
first single experiences of the immediate past, which naturally is also
the period of disease, are irregularly forgotten; these gaps increase

slowly and with fluctuations; they coalesce until the last years disap-
pear from the memory at first in part, then entirely. Then in the
course of years the limits of recollection are pushed back farther and
farther and at last the patients live only in their childhood. An old
woman, who in the ninety years of her life had changed her residence
several times, at first believed herself in her last residence, then in the
next to she returned to her birthplace. Another
last, etc., until at last
patient was coming from school. It is very common for senile

just
women to give their maiden names, to believe that they have just
;

recently been confirmed and to have no recollection of their marriage
and their entire adult
life. The most important events, such as the
husband's death, can be told to the patient in this stage several
etc.,
times within a few minutes and they always conceive the information
as something new with the corresponding emotional reaction; they
themselves are untiring in recounting the same news; in severe cases
they not only do not know what they experienced the day before, but
under certain circumstances forget everything from one minute to
another. Sometimes, however, experiences that intimately concern the
personal complexes are retained like memory isles; it may be an unjust
accusation or an attempt to obtain money from a stingy old man, etc.
As in paresis practiced streams of thoughts also are sometimes still
capable of relatively good reproductions.
Lively natures fill up the memory gap with spontaneous confabula-
tions, they tell fantastic stories of what they have accomplished and
experienced; in torpid natures the symptom has to be provoked by
questions. Many of these people do not like to say "I do not know"
and produce an answer invented for the occasion which they themselves
believe.
The range of ideas ismarkedly restricted, even though the lack of
critical ability rarely, and then much later reaches the high degree
as in paresis.
In the first years the patients usually try to act as usual; only
torpid and depressive cases give up the active relations with the
environment. But then actions become clumsy, unsteady and finally
entirely senseless. Because of their lack of -thoughtfulness they permit
themselves to be misled into stupid financial transactions and uncalled
for gifts and bequests. Seniles are favorable material for legacy
hunters not only because they will die soon but especially because they
are helpless against clever external influences. The attempt to obtain
the fortune is frequently made by way of marriage in which case the
heightened sexuality in many patients offers a good opportunity. In
a great many cases the external forms are retained for a long time.
A woman entirely unknown to me, about whom I was consulted, re-
ceived me as a female acquaintance (although she could see very well)
she entered into a conversation with me in the usual social phrases
without making a single slip, aside from the fundamental fiction, she
asked what my children were doing, said that it pleased her that I
had at last come again, and remarked that it was cold but pleasant
weather, etc.
Some do not feel comfortable anywhere, especially at night. With-

out purpose, or with unclear ideas, or to look after their things, they
THE INDIVIDUAI. MENTAL DISEASES 289
wander about the house spook-like with u li^ht and consequently often
become dangerous. In the hist stage real deliria are usually added,
especially those occurring at night; the patients then live in hallucina-
tions of experiences of youth but also in other adventurous and, usually
in emotionally accentuated phantasies.
Perception and attention are gradually changed in the sense of the
organic disturbance.
Orientation is disturbed rather late, often at first transiently at
night, then also during the day. The patients no longer know what
year it is, often not even the century, and when the year has been
told them they are not capable of reckoning their age, usually state it
incorrectly, even when they know the year of their birth, as they often
do. They can mistake day and night though in the nightly excitations
they want to go to their customary daily occupation more frequently
than they mistake the day for the night. Sometimes they themselves
feel that they are in a confused condition; one of our patients has
maintained for two years that she is at home and sleeping, and that
her being here and everything she experiences here is only a dream.
In the last stage disorientation also affects the simplest situation.
Then it is particularly characteristic that anxious senile patients, when
they have to be lifted or carried, grab hold everywhere of people and
doors and every object that they can reach, wherebj' they naturally
increase the danger of falling.
The large majority of seniles have only these basic symptoms; it is
a case of simple senile dementia analogous to simple paresis and simple

demented schizophrenia. But these people rarely come to the insane
asylums; their death is awaited in their families and in the poorhouses.
But various accessory symptoms can change the picture and often
make institutional care necessary. Even among the simple senile cases
some are more torpid, others more The
torpidity can increase
lively.
which the patients who are
to stupor, the liveliness to an erethism in
in continuous activity combined with a talking mania can hardly be
made to rest. The mild affective displacements which are frequent
in old age can rise to melancholic and manic conditions, of which the
first are very frequent, the second rather rare {senile melancholia and
mania) The depression is frequently accompanied by anxiety though

.
perhaps less often than in the arteriosclerotic forms.

In such affective conditions delusions are invariably formed, and
depending on the mental state they are either delusions of insignificance
or greatness. The latter is always very weak and does not attain the
multi-colored and fantastic magnitude of the paretic delusion. In the
depressive delusional forms the delusion of poverty usually recedes
before the horribly developed delusions of sin and hypochondriasis.
These are often accompanied by nihilistic ideas and ideas of enormity,
which are specific in organic diseases, and occasionally also by micro-
manic ideas, the patients believing themselves or some parts of their
bodies to be very small, which gives them occasion for anxiety and
justification of the anxiety. The mere poverty of ideas is shown in
the following complaint; "I must make so much water; the nurse will
not empty the chamber; what will happen? I have such parched feel-
ing and what if the nurse will not give me any water? And when this
jacket is dirty, then they will send me one thatis too thin."
Very often these affective delusions are mingled with delusions of

suspicion, self-reference and of persecution; the delusion of being
robbed is something quite common in senile diseases.
Even in otherwise simple forms delirious conditions with hallucina-
tions occur in the final stage. Individual hallucinations may now and
then be noticed earlier; it is generally a case of auditory and also visual
hallucinations. Hallucinations of smell and taste are rare. The
patients see and hear dreamlike transactions ; for instance, they live in
a previous activity, or like presbyophrenics, they busy themselves with
mixing everything up, packing their beds and all their things together,
in order to go "home," etc. The term "occupational delirium" is also
used in this connection, but in the forms of senile dementia not com-
plicated with alcoholism the picture is entirely different from that in
delirium tremens. In the latter there is an uncertain complicated
pseudo-activity in individual, not really connected parts. The patients
believe that they are sitting in a bar-room, that they are writing,
driving, while they may be lying on their backs in bed, or if they are
walking about they do notice that something is wrong, whereas in
the senile patients, it concerns mostly real acts, even if they appear
decidedly purposeless.^^ Many, even those who are relatively clear,
collect useless rubbish, they go to the street to look for things that
the children have carried away, "they look for something, upset the
bed, tear open the mattress, mix up the horse hair, tear up the linen,
frequently cover themselves with it in a phantastically senseless
manner" (Fischer). If they are not confined to the bed they busy
themselves incessantly with something that, though producing little
that is comprehensible, always pursues some idea. It is only with the
complete decline, that the stereotyped movements come which corre-
spond to the previous occupation (washing and sewing motions, etc.)
The patients then often become unclean, not only because of careless-
ness and paralysis, if not carefully watched they readily begin to
" Comp. p. 237.
play with the excrements. Such conditions, which in their higher

developments must be designated as severe deliria, occur at first most
frequently at night or they last, as transient excitations, for days and
weeks, or finally, near the end, they form a chronic condition that may
continue for months and years.
Other accessory symptoms result from local disturbances in the
brain which are not directly a part of the disease but naturally appear
frequently as a result of the arteriosclerosis that exists at the same
time; among these we have paralyses, aphasic and apractic disturb-
ances. The spinal cord is usually also involved more or less, so that
the sphincter muscles and the (lower) extremities also are no longer
controlled properly.
Fig. 9.The handwriting of a simple senile dement of the lighter grade, show-
ing regular tremors. The patient took great pains to WTite very carefully.
The physical symptoms are otherwise chiefly basic symptoms which

correspond with the general cerebral atrophy among which we find:
clumsiness, stiff weak motions, and finally marasmus. INIetabolism is
retarded very early, the appetite frequently disappears, the hand-

writing becomes shaky and in many cases is clumsy in other respects.
Sometimes the tremor is entirely regular but rather coarse. Other
manifestations, as the shrinking and the decrease in the elasticity of
the skin, the arco senilis in the cornea, etc., are expressions of the
general decrease in vitality, to which the brain atrophy also belongs;
they are, therefore, parallel manifestations, which in relation to the
brain disturbance may be developed to very different degrees.
On the basis of these accessory symptoms different forms have been
distinguished.
If there are no accessory symptoms at all, we have senile demejitia
in the narrower sense, or the simple form of dementia senilis. The forms
with affective displacements, such as the senile melancholias and
manias, are probably the commonest among the institutional cases.
That these names designate only the acute pictures with which the
patient usually comes to the physician, need not be so important,
because as indicated, the moods are usually still recognizable in the
quiet period also.
The forms showing a clear sensorium with delusional formation
and eventually hallucinations are designated as senile paranoia (or
paranoid forms of dementia senilis) they are not frequent. Such

;
people think they are spied on by neighbors, teased, robbed especially

by those living in the same house, they find everywhere references to
themselves, and confirmation of their ideas in voices, etc.
In dementia senilis, as in paresis, catatonic-like forms have been
spoken inasmuch as one observes stereotype movements and atti-
of,
and echolalia. Many of
tudes, verbigeration, flexibilitas cerea, stupor,
these cases, as the anamnesis and other symptoms show, are undoubt-
edly (latent) schizophrenics that have become senile. In others the
stereotype movements prove to be remnants of habituated movements
(twisting the moustache, scratching). What gives the impression of
verbigeration is often plainly nothing but the incessant expression of
the identical feeling that always dominates the patient, as in such an
expression as ''Oh, God, help me!" or it represents an organic preserva-
tion in which the patients want to say something else but invariably
slip back into the once trodden path. The echolalia may be an organic
disturbance which is probably somewhat differently conditioned than
in schizophrenia. But as yet we do not know enough, and can only
insufficiently analyze these invariably severely demented patients, in
order to make an exact differentiation in the individual case between
schizophrenic and organic-catatonic symptoms.^^
The course of simple dementia senilis is usually very slow; it may
extend over a decade. The weakness sets in very gradually; not even
the year in which senility merges into disease can be regularly deter-
mined. With minor fluctuations the dementia and the physical weak-
ness gradually increase; extensive remissions are not to be expected
here.
Also the paranoid forms with complete clearness usually run a
decidedly chronic course, but the delusions are subjected to some-
what severer and more frequent fluctuations, so that really bearable
conditions can sometimes alternate with those that are almost
delirious.
Acute shifts with total confusion can appear very early and under
certain conditions can disappear after a few weeks or months, so that
"^
Compare p. 236.
Wernicke e.g., may talk of cures. But even if the patients do not die
soon, new and definitive exacerbations are to be expected.
Senile manias and melancholias can heal, the manias very often,
the melancholias less frequently. But many of the latter are also
disposed to gradual improvement. However, the senile dementia then
remains, even though it is often noticeably of slight force. But as in
paresis the affective forms tend to a lasting displacement of the affects,
since after the storm has run its course a milder euphoric or depressive
mood remains. Senile melancholia can even maintain itself for years,
up to death, on the same plane of melancholic depression.
Anatomically senile dementia proves
to be a diffuse reduction of the entire
central nervous system. As in paresis
the convolutions are narrowed, uneven
at the surface, the ventricles are wid-
ened, at death the entire brain is re-
duced just as much as in arterio-
sclerosis.
The pia is clouded but hardly
really opaque, just as little is it in-
filtrated.
The ganglion cells disappear in
different ways. They dissolve, they
Fig. 10. Pyramidal cell in a
undergo fatty or pigmentary degenera- simple dementia senilis. The well
tion, and vacuoles are formed in them.
preserved fibrils (clearer in the
specimen) form a net about the
The glia hypertrophies, but more as to fat droplets that fill up and bulge
the number of the elements than in out a part of the cell.
thickness of the fibres or in size of the
cells ; in contrast with paresis the cells usually remain relatively small
and delicate, and the fibresremain thin; mitoses are rarely seen (except
in acute lesions). In addition, debris and products of cells are natu-
rally found.
The causes of senile dementia are still quite obscure; undoubtedly
the hereditary disposition plays a part. The maximum of the disease
lies in the age between sixty-five and eighty years. The disease afflicts
both sexes about equally.
Early waning of the trophic energy of the brain occurs especially
in oligophrenics (sometimes as early as in the forties), in akoholics
("Dementia alcoholica senilis," Ford, with transition to chronic
Korsakoff of earlier age), in manic depressives, and in endocardiacs.
Not rarely acute debilitating diseases, like pleuritis, or fracture of
the neck of the femur, etc., occasion the outbreak.
Dijferential Diagnosis. The most difficult thing in the diagnosis is
to differentiate from "normal" senility. Where the line should be
it
drawn is arbitrary. For forensic purposes one must depend on the

practical considerations; all things being equal, a wholesale merchant
should be declared insane and incompetent even if he shows less severe
disturbances than a day laborer in the same state. Indeed, under rare
circumstances a few harmless delusions will not yet induce us to declare
the patient practically as mentally unsound, while naturally in the
medical sense all such cases are pathological in the same way as those
showing a noticeable affective displacement.
The disease is distinguished from arteriosclerotic insanity by the
absence of arteriosclerotic and local manifestations, by the more gen-
eral affection of all functions, and the greater steadiness of the course.
But the frequency of the combination of both diseases may cause
difficulties which are fortunately chiefly of a theoretic character only.
The melancholic and manic states are recognized as senile by the
organic signs of the disease, the lability of the affects, and the sense-
lessness of the delusions, etc. The weakness of the memory is sometimes
revealed by the fact that the affects exert an abnormal influence over
it. Thus a melancholic patient in the incipient stage of senility, whose
memory otherwise appears to be still completely intact and who is also
still capable of work to a considerable extent, may be noticed by the
fact that he forgets (it is not a blocking) all pleasant experiences,

while he retains very well all those that correspond with his mood.
Treatment: For the prophylaxis of senile dementia we know noth-
ing that can be done except to avoid all the ordinary nervous injuries,
above all alcohol. Besides the physician must be careful not to create
situations that may
act as causes. Old people suffering from a fracture
of the neck of the femur, whenever possible, should not be long confined
to the bed, etc.
When the disease has once broken out it naturally cannot be cured.
The general principles of therapy in the senile psychoses should be
symptomatic. 2*
Presbyophrenia
Presbyophrenia, the classification of which to be sure varies accord-
ing to the author and even in the same author at different times, is,
according to some, a special morbid picture, according to others a

variation of dementia senilis. According to the present state of the
question, a morbid picture is best called presbyophrenia which in its
typical cases is very^ well characterized. It always presents the general

" Sec p. 279.
THE INDIVIDUAT. MENTAL DISEASES 295
signs of dementia senilis, but shows Ijcsidcs a peculiar excitation and

an alteration of thinking that extends beyond the ordinary senile dis-
turbance. The patients are always engaged in an apparent activity;
as long as they walk and can orient themselves at least in their im-
mediate surroundings, they fuss about incessantly, things are mis-
placed, carried to another place, everywhere something is looked for,
and all of this, without anything being really accomplished. If the
patients are weaker, they cannot lie in bed decently even there they ;
are occupied, they sit in any old way, and stretch their legs out of bed.
With uncertain but eager motions the bed clothes are pulled together,
twisted together, tied into disorderly bundles or only moved and
rubbed together (the patient "is
washing") Despite a good affective
.
rapport with the surroundings, per-

sons, places, situations, and times
of day are mixed up, just as much
as the bedding. As long as the pa-
tients can talk there is a certain
talkativeness, behind which, how-
ever, there is no flight of ideas un-
less something manic exceptionally
supervenes; at all events they
readily lose the thread merely be-
cause of weakness of memory. For
Fig. 11.

"Washing" presbyophre-
the most part they get a special
aic. In spite of the demented ex-
kind of speech disturbance in which pression one can see the eagerness
at times they no longer find the in the activity. Unfortunately the
resuhs of the occupation, the dis-
words, or misplace, repeat, and
order of the bed, are not visible in
mutilate them, and cling to single the picture.
syllables that either do or do not
belong to the word, and produce alliterations and permutations, as well
as logoclonus, etc., but at the same time, at least in the beginning and
when stimulated, they give entirely correct answers.
An example
cited by Fischer'-^ illustrates this best: ''iMother of
God, Virgin Mary, our lord, our dord thour dord, dord, dord dord,
de dede deOh now just listen, blessed fruit of the body, give us
this day your our ours, holy Mary pray for usars, so that we much.
. .Our Lord our dord so that we shall do much. Come you lousy
.
fellow come quly, dosoorly sanctify our lord, you lousy fellow, than
art among women, the fruit of the body, Jesus well yes, that is the great
^'Ein Beitrag zur Klinik imd Pathologie der presbyophrenen Demenz.

Zeitsch. f. d. ges. Neur. u. Psych. Bd. 12, 1912, p. 125.
one, but thou thinkesest holiest our Lord, our lord, then and here is
certainly certainly sanctified himself himself, but thou felt for the
sinners and have sanctifieth all sinsand misdeeds our lord, our lord has
made forbad and fruit of the body well he has give it ever. ," . .
Typical epileptiform attacks are not rare in presbyophrenia. Hal-

lucinations and delusions, concerning which more exact information is
naturally not easily obtainable frequently exist, but are not at all
necessarily as a determinant for these peculiar confusions.

In the cases thus classified one finds in the brain regularly, and
in especially large numbers, the senile plaques of Fischer (sphero-
trichia), the significance of which is not yet clear.-'' In the other forms
they rarely occur, so that the morbid picture is kept together even
anatomically to a certain degree.
Kahlbaum, who coined the name presbyophrenia, understood it to
mean senile psychoses; Wernicke made a morbid picture of it which
he identified symptomatologically with Korsakoff's disease so that the
conception corresponds approximately to a "simple senile dementia,"
the torpid forms excepted. Kraepelin then required relative retention
of the order of the mental process and even of judgment, without
keeping strictly to these qualifications. Fischer found somewhat later
in his anatomical spherotrichia a definite morbid picture, and he also
put the disease parallel with Korsakoff, but in many of his cases it
went bejônd Korsakoff in the far greater alterations of thinking, and
it corresponded in part with the one pictured above. But finally pretty
nearly every dementia senilis which is colored to a considerable extent
by accessory symptoms came to mean for him presbyophrenic
dementia, thus the melancholic, manic, paranoid, and catatonic forms
(ever>i:hing with the exception of his "arteriosclerotic pseudopresbyo-
phrenic dementia"), which correspond practically with the forms of
our erethic arteriosclerotic insanity.
Not to be separated from presbyophrenia for the present is
Alzheimer's disease in which one deals with a dementia, beginning

early, in the sense of presbyophrenia, but which in a few years leads
to a particularly high degree of dementia with aphasic, agnostic, and
apractic symptoms and finally results in death. In exceptional cases
it maybreak out in the forties. The anatomical findings correspond
qualitatively about with presbyophrenia but it is very intensive; there
is a general cerebral degeneration with destruction of the fibrils and
numerous senile plaques; but cases are also included in which the one
or the other of the last two distinguishing features is lacking.
Course. The presbyophrenic forms usually exhaust themselves
"See below anatomy.
within one or two years, often already in a few months after the dis-
ease has become manifest. Tiie more acute the cases, the more are
fluctuations to be expected; many of the slower ones run an entirely
straight course until death.

Fig. 12. Cortex in presbj'ophrenia. a. Cross sections of large senile plaques,
b. Degenerated fibrils stuck together, c. Fibrils stuck together into the form of a
fihng as the remnant of ganglion cell.
Anatomically besides the general brain atrophy with hypertrophy

of the glia the senile plaques are characteristic {Fischer's "Sphero-
trichia," "senile plaques," Simchowicz) Their significance as yet is
.
in no way clear. Formations are involved that appear threadlike or

Fig. 13. Presbyophrenia. Senile plaques in the brain cortex.
Fig. 14. Presbyophrenia. Senile plaques. More strongly magnified.
roll themselves together in balls, and include nervous and gliose ele-
ments in a trancformed condition; they usually form conglomerates

that can far exceed a ganglion cell in size and are scattered every-
where in the brain.
In a large part of the cases with senile plaques one can see a severe
disease condition of the fibrils which is not visible in ordinary senile
dementia. The fibrils bubble up and drop together into irregular

forms. Sometimes, e.g., in Alzheimer's disease, they form peculiar
tangled bundles.
Differential Diagnosis. Pronounced presbyophrenia can hardly be
mistaken. It is often compared with alcoholic deliria. In part the
deliria are colored in that way by accompanying alcoholism. In most
cases it is purely a question of imperfect differentiation. Deliria with
hallucinations of sight are not necessarily alcoholic
deliria. For this diagnosis all or, at any rate, most
of the symptoms must be characteristic. But
above all the state of consciousness and the reac-
tion rate in both diseases is so different, that usu-
ally the diagnosis ismade at the first glance. The
alcoholic can be roused much more easily, and has
a quick conception and rapid reactions; the senile
demented rarely gets into proper touch with the
environment and his percejDtion is slow. Perhaps
the good-natured rapport also, which is rarely -p
r_Xormil
entirely lacking even in the deeply confused senile cortical cell. Stain-
but is rare in the confused alcoholic, can be utilized ing of the fibrils,
in the diagnosis. To recognize it immediately

one must have seen the difference between the presbyophrenic eagerness
for occupation and the alcoholic occupation delirium.
Especially the slower reaction capacity, the mood, and frequently
also the age, distinguish the presbyophrenic as well as every other
senile delirium from the alcoholic Korsakoff.
The causes of presbyophrenia are unknown.
The treatment of the unyielding disease is purely symptomatic.
VI. THE TOXIC PSYCHOSES

1. The Acute Toxemias
Among the acute toxemias Kraepelin includes Uremia which is

important inasmuch as epileptiform attacks occur in it, and because
it can stimulate any cerebral local symptoms. The uremic psychosis
as such usually runs its course with a picture of various deliria, whose
specific peculiarities, if they have any at all, are not yet kno\s-n; it
proceeds in the majority of cases to a rather sudden death.
Eclampsia of pregnancy and child bearing is recognizable by epi-
leptiform attacks, besides which there are also occasional delirious
conditions.
In carbon monoxide poisonings after the patients emerge from
the narcosis, they may run their course with a picture of twilight states
lasting for hours or days. Central and more peripheral paralytic mani-
festations often complicate the disease. If the patients do not recover
entirely, then the organic symptom complex, accompanied usually by

conspicuous severe memory defects and depression, remain as an ex-
pression of the diffuse destruction of the brain tissue. Between the
first toxic sleep and the later developments of the symptoms several
days or even weeks, free from disturbance, may intervene.
Of the remaining toxemias we unfortunately have more toxicological
than psychiatric knowledge. Only alcoholic inebriation is more
exactly known even though we should know still more about it. Its
every day forms are ignored by psychiatry but several unusual kinds
;
of manifestations require special consideration:
^^
Pathological Drunkenness
The acute effects of alcohol are, as is well known, individual and

very different according to chance circumstances. Sometimes such
fluctuations lead to quite abnormal reactions which, as far as they are
of practical importance, are gathered together under the name of
pathological drunkenness.^^ Even "maudlin drunkenness" an abnor-
is
mal reaction but it is not included here. Pathological states of drunk-

enness are sudden excitations or twilight states set free by alcohol,
usually with a mistaking of the situation, often also with illusions and
hallucinations, and excessive affects, mostly of anxiety and rage. In
individual cases the entire morbid process can transpire in hardly a
minute but it usually lasts longer, up to several hours.
Among the predisposing factors that are regularly found, there are
lasting and accidental causes. To the first belong all kinds of neuro-
pathic dispositions, above all epileptic and schizophrenic, according
to Heilhronner, frequently hysteria (e.g. among prostitutes), and cere-
" Heilhronner. t)ber pathologische Rauschzustande. Miinch. Med. Wochen-

schrift 1901, S. 962.
" The name "complicated drunkenness" has been proposed because every
drunkenness is supposed to be pathological. But the ordinary name, aside from
its theoretical justification, is of practical value especially in the courts, because
there it is a question of "morbid or not morbid?" Formerly one spoke of
"mania ebriosa" and similar terms. "Senseless intoxication" differs from patho-
logical drunkenness in the fact that in the former no qualitatively unusual
symptoms have to be visible.
bral traumas. It is self-evident that the disposition is not to be

mistaken for alcoholic intolerance, in which small quantities have a
disproportionately strong effect but without the inebriation having
to be qualitatively abnormal. Chronic alcoholism also can lay the
foundation for pathological drunkenness since many drunkards first
become disposed to it when they have reached a higher degree of
alcoholic degeneration.
To the transient dispositions belong all influences that weaken the
body, such as over-exertion, waking at night, excessive heat or cold,
then, as is well known, affective excitations, sexual excitement, and
"drinking oneself into a rage."
Under such circumstances very small quantities of alcohol, such as
two glasses of beer, can often provoke an attack. At first one does
not notice anything wrong with the patient, then he begins to be
irritated or anxious in order to rave and storm against persons and
things about him. The paroxysm is sometimes set free by any occa-
sion, an exchange of words, an attempt to direct, the intervention of
a policeman, or without visible cause the drunkard hurls himself at
some one just entering. Thus a student suddenly hurled a full salad
dish at a classmate's head; it was evidently due to a spasm of ocular
accommodation; his comrade seemed to him so tremendously dimin-
ished in size that he wanted to make certain where he was and how
big he was. It also happens that at first these persons go to sleep
and then wake up in a rage, or when they are awakened feel them-
selves threatened and seize a knife. The confusion is sometimes begun
by an epileptiform attack. Even though rarely, attacks of this char-
acter may occur also during the paroxysm; according to Heilbronner
there are also pathological states of drunkenness whose motor mani-
festations consist chiefly of senseless rhythmic movements.
In these excitements alcoholic disturbances of coordination, such
as paralysis of the tongue and staggering,-^ are lacking.Usually the
head is extremely congested, and one may also observe the pulsation
of the carotids. The expression of the eyes is often somewhat of a
stare. Under the influence of illusions and hallucinations of sight, and

more rarely of hearing, the conditions of tlie surroundings are mis-
taken. The patients are usually markedly disoriented, sl:iowing
"anxious phantastic fears," and are dominated by terrifying delusions
of reference. More rarely they act on the basis of some isolated,
usually unclear conception, as in somnambulism, and set fire to a
'^
To be sure, this is partly due to the fact that one does not like to include
drunkenness with coordination disturbances, among the pathological. But in
this case, also, there are no sharp divisions.
,

house in a rather peculiar way, etc. {alcoholic twilight state). The
picture may also resemble delirium tremens or acute alcoholic insanity.
Nearly always the scene is ended by a protracted narcotic sleep
from which the patient awakes with a dizzy head, but as a rule,
without any recollection of what has happened. In less frequent cases
the amnesia is not complete, or it appears later, perhaps in the course
of the following day, at times only after the patients have already
admitted having committed a crime.
There are people who have such attacks only once in their lives;
others, especially heavy drinkers, may be so afflicted very frequently.
But, as far as I know, the above described alcoholic effects are always
the exception in the same individual; he also has spells of normal
drunkenness. To be sure there are drunkards who, finally, in nearly
every drunken spell get "drunken hallucinations/' sometimes in the
sense of delirium tremens, sometimes more in the sense of alcoholic
insanity or of alcoholic jealousy, but here the reaction is usually a
much milder one. Even where there is fighting, raging and stabbing,
it does not occur so blindly but with a certain consciousness of purpose
and with a consideration of real things and persons.
If pathological drunkenness recurs in the same person, they often
have a great similarity.
The differential diagnosis is based on the demonstration, first, of
the dispositioUj then of the disturbance of orientation (in which nat-

urally the proper recognition of single persons, or of a single street, is
not at all excluded), then of the externally unmotivated anxiety or
anger (the latter can apparently originate in a quarrel preceding the

drunkenness, which in reality caused the disposing affective agitation)
then on the demonstration of false perceptions, the lack of disturbance
of coordination, and perhaps the continued raging when the patient
is put to bed (ordinary drunkards usually fall asleep very quickly).
When the critical sleep is not followed by the amnesia, then it will
be difficult to assume pathological drunkenness without other, very
plain morbid symptoms, such as hallucinations and disorientation; on
the other hand it must be especially emphasized that ordinary drunken-
ness not rarely completely wipes out the memory. If it can be demon-
strated that the quantity of alcohol imbibed was so small that normally
it does not cause any manifestations of intoxication, then the patho-
logical element cannot be disputed, although this does not yet directly
demonstrate the disturbances of reflection.
Treatment. In case the patient still raves when he comes to the
physician, restraint can rarely be avoided. Efforts to convince the
patient through talking does not help. In one case, however, a col-
league was able to put a patient to sleep by hypnotism, while he was

in the act of destroying his room, whom we had previously hypnotized
into sleep. Of the narcotics only hyoscine (with morphine) is to be
used; but even the largest permissible doses leave no certain effect.
On the other hand, when necessary, one can resort to a real narcosis
through ether or chloroform if the heart can be carefully watched.
2. The Chronic Intoxications
A. Chronic Alcoholic Poisoning"
The Simple Drinking Mania
Theoretically alcoholism and drinking mania should be distin-

guished. He who cannot abstain from spirituous drinks even when
he realizes that it would be better not to drink, he who habitually
oversteps the measure which he himself considers proper, is a drinking
maniac; he who shows other psychic results of drinking or physical
alcoholic signs, is an alcoholic. But the two diseases cannot, how-
ever, be sharply separated, if only because the drinking mania on the
one hand, if it is primary, usually leads in time to alcoholism, and on
the other hand it appears secondary as a symptom of alcoholism, so
that both syndromes are mostly encountered in association.
In other drug manias ^ like morphinism, it is not so essential to
distinguish the mania from the consequences, because only the chronic
morpho-maniac takes too much morphine, and as a rule he also shows
soon the other symptoms of morphinism. But as alcohol is generally
taken for enjoyment and nourishment, there are plenty of people who
become alcoholics who usually do not drink more than what they and
the environment consider right, that is, they become alcoholics without
being drinking maniacs. This becomes most striking, when such people
get delirium tremens on the occasion of an injury or pneumonia, which,
to be sure, one then prefers to designate as "fever delirium."
Under drinking mania we therefore include all those cases who on
the basis of a disposition, or habituation cannot give up the enjoyment
it to a "harmless"
of alcohol, despite better insight, or cannot reduce
amount, but who do not show the symptoms described under
(still)
the manifestations of chronic alcoholism. If added signs of chronic

poisoning supervene, we designate the disease as chronic alcoholism.
As in the case of any other mania the drinking mania afflicts particu-

Psychological and national economically it would be of interest to go
'"
deeper into the study of the "Tobacco mania." The latter, however, is of
slight significance medicinally.
larly psychopaths of every description; but there is no question that
the essential factor in many cases of simple habituation is based on
our drinking customs and the false view of the harmlessness or even
the usefulness of regular enjoyment of spirituous drinks. As a matter
of fact one should not go too far in tracing things to "psychopathies."
Is there any one in whom
one cannot find some deviations from the
normal or even verify them? We shall therefore speak of a "simple
drinking mania," where the mania is not yet complicated by other signs
of poisoning, regardless .of some, though not considerate, psycho-
pathically predisposing factors.
The treatment of the drinking mania is the same as that of chronic
alcoholism.
The symptoms have since the time
of chronic alcohol poisoning
of Magnus Huss been described under the name of chronic
(1852)
alcoholism. There are physical and psychic symptoms, of which the
former are of special importance for the psychiatrist, because proof
of their existence can make the layman comprehend most readily that
a "disease" is involved.
dilatation of the blood vessels, especially in the face, which
The
in milder cases also causes the skin to appear more red, is generally
known. In some severe cases the dilatation of the veins on the nose
and the adjacent parts of the cheek is especially conspicuous; finally
the color may turn more into blue and in some cases acne rosacea
develops. But in most alcoholics there is no such a marked
disfigurement.
The excessive use of alcohol is mentioned as one of the causes
of arteriosclerosis. I do not know whether this is right.
The heart shows an alcoholic fatty degeneration which may heal
with abstinence and reappear with the resumption of drinking. It
is the most important cause of the usual symptoms of inadequate
circulation, irregular pulse and enlargement of the heart ("beer

heart") ; chronic myocarditis also is evidently found more frequently
in inebriates than in others.
A disease that is usual in alcoholism but is otherwise not at all
frequent is chronic catarrh of the stomach; cirrhosis of the

the real ^^
liver is practically always alcoholic, while fatty degeneration of the

liver is frequently so. It is supposed that there is an alcoholic atrophy
of the kidneys.
General nutrition varies greatly. In the severe cases there is either
a bloated appearance or more or less pronounced marasmus, the former
chiefly in the beginning, the latter in the later years of the disease.
^ What is otherwise so called is usually a nervous affection.
The well nourished shapes are said to keep more to beer and wine, the
ethers are said to be whiskey drinkers.
In the advanced stages, functional disturbances are nearly always
present. Well known is the tremor which under ordinary circum-
stances is regular and fine and only in severe cases develops into a
coarse disturbance of motion; it is usually most marked when the
patient is sober, and may force him to drink his first glass in the morn-
ing directly from the table because he might spill it with his hand.
The patients often know instinctively how to render the trembling

Fig. 16. Handwriting of a chronic alcoholic of 63 years, who drank heavily,
mostly whiskey for about 45 years. The characteristic tremoi-s are plainly visible,
and increase with fatigue, as shown in the last lines of the two examples.
harmless or to conceal it thus if the physician extends his hands and

;
spreads out his fingers and requests the patient to imitate him, he
extends his hands but does not spread out his fingers because they
would show a (greater) tremor; the patient has to be especially re-
quested to do so. In some cases the affection can be completely
neutralized for a short time by mere self-control.
The tremor rarely also affects the eye muscles in the form of
nystagmus.
Besides, twitchings in various muscle groups are seen now and then,
a tendency to cramps in the calves of the legs, and in the severer stages
.

the drunkards become weak, their walk is unsteady, the face becomes
as flabby as in the paretic.
In the stage where the patients come to an institution the pupils
often react badly, theymay also be unequal, but after some abstinence
nearly everything is normal. Alcoholic optic atrophy with a paling
of the temporal side of the papillae and color scotoma is known, though
it is relatively rare. Still rarer are chronic paralyses of the eye
muscles.
The deep reflexes are often increased according to the state of
anatomical degeneration; more rarely they are diminished or absent.
In the sensory field one often finds on closer observation a local
reduction of sensitiveness in individual skin areas, especially those of
the lower leg, as a result of the degeneration of particular skin
branches; more deeply vague pains appear which are likely to be
treated as rheumatic. A heavy head, dizziness, mouches volantes,
buzzing in the ears and similar affections are usually signs of the con-
tinued acute poisoning.
The digestion often becomes irregular. Vomitu^ matutinus, which
is only produced by alkaline saliva, is a common and pretty sure sign
of chronic alcohol poisoning (in women, pregnancy is to be excluded)
Sleep is irregular, at times poor, restless, at times heavy. Higher
grades of alcoholism manifest themselves among other things also in
the need of imbibing the necessary "night cap" before retiring.
Potency declines in the later stages and often sinks to nearly noth-
ing; the libido,which in the beginning is usually strongly aroused,
usually maintains itself longer. There is a diffuse atrophy of the
testicles in the severer cases.
Single epileptic attacks may indicate the severity of the cerebral
poisoning; they follow particularly after especially heavy drinking
bouts, but in mere alcoholism they are not nearly so common as in
delirium tremens.
In the descriptions of the psychic disturbances "ethical degenera-
tion," the "blunting of the finer feelings," the"moral coarseness" are
invariably emphasized. important to state that this characteriza-
It is
tion in the manner in which it is usually expressed is not true to facts.
The alcoholic, who was originally decent, remains the pleasant, cordial
companion in his singing society and in drinking circles; he can shed
warm tears at his neighbor's misfortune, become wildly enthusiastic
about political or any ethical purposes not only can he state, but even
;
feel what is good and bad; he can give wonderful advice to others;
if he is an artist or poet, he can create works of art that indicate a
fine sensibility even in the realm of ethics and good taste. On occa-
sions where the affectivity is not involved, his judgment is quite good
until a fairly advanced stage of the But notwithstanding
disease.
this, the description of the disgusting coarseness and the inconsiderate
actions of the alcoholics is not mere fiction; such people act thought-
lessly under the influence of the affect and are coarse under certain
circumstances, e.g. at home, where they have to feel the expressed or
mute reproaches of the family, at work where they cannot hold them-
selves and which they subordinate to their drinking pleasures, and
in a quarrel in certain stages of drunkenness. The great majority of
inebriates is made up of those who were originally well disposed and
who are still capable of finer feelings. Besides them there are others,
who have "gone to the dogs" in all respects; some are weaklings who
always permit themselves to be misled into following the customs of
their environment and to whom vulgarity in this way becomes a habit;
others are sick persons whom alcoholic atrophy of the brain has made
into irritable and thoughtless children of the passing moment. The
third class consists of those who are naturally coarse and generally
morally deficient but who lose,through alcohol, the inhibitions that
otherwise restrain them a little. To be sure most of our work as
psychiatrists is with this class, but their vulgarity does not result
from alcohol it is only made apparent and increased by it. Only the
;
last two categories correspond with the usual picture. The three men-
tioned constitute the main forms between which, and beside which,
there are transitions and combinations that can be readily ipaagined.
It is because on suitable occasions alcoholics can command in all
sincerity the finest sentiments, that these people become dangerous
and attractive; they are not hypocritical in this respect. They can
still occupy important public positions without attracting attention
to themselves, even though at home they beat their wives, walk naked
into the kitchen before their children, etc. They believe on appro-
priate occasions, that they want to do everything for their families,
can show the loveliest remorse and can make still finer promises.
Whoever does not know them well, must believethem because they
themselves believe in their own uprightness. But with the first change
in the external situation the fine feeling also gives way to another that
is just as sincere and that takes hold of the entire man just as
much.
A mother of thirteen children is stricken with cancer of the womb.
The alcoholic husband visits her solemnly every Sunday in the hos-
pital, bringing her flowers. Finally it is too much for him to spend
the few pennies and he demands that his wife be sent back. At home
he maltreats her as before and, as the carcinoma has a strong smell,
he regardlessly indulges at the table in the gruesome joke that now
they had potatoes and crab (cancer) for dinner.
The following was brought to light in a court case: After par-
taking of cider and four deciliters of whiskey an alcoholic had misused
one of his children and had attempted to misuse the other in his wife's
presence. He had boasted to his wife that on her communion day
he had taken her innocence. He sent another child to the mother with
the news that he was about to tear out all the hair from the pubes
(this in the most disgusting expressions). He had beaten his wife's
body black and blue, and wounded her head, scalded her with hot water
and peed in her face (perhaps to treat the wound without a doctor).
The beating lasted two days, in which time the children had to hold
the mother once so that he could hit her with a rope. At last the
woman could escape in her shirt to a neighboring house; the man
remained at home. After two days a neighbor brought him some milk;
one could not let him starve. Then the villain was so penitent and
shed such bitter tears that the neighbor, a farmer, began to weep
also, brought the wife and the children then everybody deeply touched
;
cried together. The affair with the children was brought before a
court, where the man maligned his wife outrageously.
The above men-
tioned beating was not at all extraordinary, only the misuse of the
children had been a novelty.
Because the customary descriptions consider completely only the
naturally coarse group and present only the darker side of the far
larger group of those originally decently disposed, the diagnosis is
usually mistaken; one does not dare to designate as an alcoholic one
whom one has just seen conduct himself so nicely and considerately.
And, on the contrary, many coarse individuals, who among other things
drink, are considered alcoholics which they are not, or in whom at
least the unpleasant psychic characteristics are not the result of
drinking.
The alcoholic ethical defect, therefore, does not consist in the loss
of ethical feelings but in the abrupt change of the feelings generally
and domination of the entire man, his mental stream and his
in the
will, by every momentary mood, by the affect of the present moment.
We have the same condition as in the so-called ethical defects of the

organics; only in alcoholics the duality is much more apparent because
the intelligence in itself is still well preserved, while in the paretic the
loss of ethical standards may appear as a partial symptom of the
general dementia.
The most important change in the feelings of alcoholics is, there-
fore, their lability with which is always associated a heightened
emotional coloring of all experiences and, with this, the complete
domination of the affects. The patient can make himself endlessly

sad over the condition of his business, over the misfortune that he
has brought on his family, but shortly after he sits in the saloon, a
carefree and cheerful companion, and a short time after that he can
become enraged and with word and deed deeply injure his best friend.
Practically, the ethical value of such a man is, to be sure, the same
as that of a pronounced moral defective; because what good does it
do his wife, if at one time he is tender, only to misuse her again imme-
diately afterwards? To do good requires time; a clumsy act, mali-
ciousness, a misfortune, can occur in the excitement of a moment.
One of Benoit's alcoholics at a dance gets into a jealous rage with
a girl, so that she leaves him. In desperation he hangs himself, is cut
down and immediately continues dancing.
The affective flightiness naturally also makes steadiness of endeavor
and action impossible. Drunkards are easily inclined to take up new
plans, to let the old ones fall and finally not to accomplish anything
worth while. The lack of a consistent mood deprives them, in the
realm of character, of the endurance and perseverance of their en-
deavors and, in the realm of intellect, of a consistent purpose. And
because reflections also are under the influence of the affects, the re-
viewing of complicated situations, in which the affects play a part,
e.g. the state of one's own affairs, must suffer as well; essentials and
details are no longer differentiated because both are strongly colored

by the feelings.
With this leveling of the feelings in the direction of enhanced vivid-
ness the striving for something higher must naturally suffer also or
be completely suppressed. The gratification of immediate wants satis-
fies the patients. This also finds expression in the ethical reactions;
the alcoholic who has celebrated blue Monday is ashamed to go to
work on Tuesday and bums the entire week; he consider it a disgrace
to enter an institution for alcoholics and overlooks the disgrace of his
alcoholism.
Also the weakness of will of alcoholics is chiefly based on the aft'ec-
tive lability. They can break the most serious promises five minutes
later, have no endurance anywhere, and for the latter reason in the
severer cases leave their positions so readily, partly to take another,
partly without any definite aim, merely because work no longer suits
them. The weakness of will naturally becomes apparent earliest and
in the most pronounced fashion in relation to their appetites.
and especially the alcoholic fickleness have still another
All of this
cause, to wit, the protracted euphoric attitude of the affcctivity which
;

makes it possible for the patient to feel even misery as good, or at
than the normal person does. A circumstance as im-
least as less evil
portant as commitment into an insane asylum is treated by most
drunkards for perhaps a week as a bad joke. The patient is "in the
hotel where the big fools are treated"; "he has quarrelled a bit too
much with his chamber maid (his wife)."
This euphoric mood is also indissolubly connected with the ideas

of drinking. The great mass of filth and misery appeals to them
affectively,even with clear insight after many months of abstinence,
as something lovely which has to be "renounced." The contempt of
society, and to be cast out among the lowest set which he formerly
looked down on with disgust, all this no longer matters to the patient
his sense of honor is gone. To be sure a colossal vanity still remains
but not in the right place. Such people boast with their mouths but
not with deeds. They brag of the number of empty glasses, of their
firmness toward their wives' admonitions, but also of things that do
not exist, of their ability, knowledge and achievements, and of their
honesty. As long as a drunkard still has this alcoholic fickleness of
the euphoria in his system it is impossible to inculcate in him an
honest pride in real and worth-while achievements. It usually dis-
appears very gradually in the course of many months of total absti-
nence, although after a few weeks in the insane asylum one usually
observes a somewhat heightened irritability which is due to a clearer
realization of the enforced confinement.
By all these affective disturbances the reflection also is indirectly
weakened: Whoever devotes his feelings to ever changing purposes,
never succeeds in thoroughly thinking out anything to its conclusions;
whoever lets himself be dominated by his affects, always thinks only
in terms of these affects; whoever is led, especially by a morbid
euphoria, to look at things only from the good side, cannot evaluate
bad chances, and continually shows wrong judgments.
But there are besides direct alcoholic disturbances of intelligence
that are not brought on in this roundabout manner, even though for
many years they are not so evident. The associations become shal-
lower and more of the external type; the typical bar-room jokes with
their word associations illustrate that sufficiently. But in more ex-
treme cases the associations become at the same time more limited;
it is for this reason that the patients find it irksome to deliberate on
complicated matters, even though there are no affective hindrances.

It is then difficult for the alcoholic to reproduce exactly. What
he tells is easily distorted by changes and additions. Especially strik-
ing is the need for a causal rounding out of a situation. In the fable
of the donkey loaded with salt/^^ e.g. many alcoholics inject a reason
why the donkey went into the water (it was warm, he was thirsty,
the burden was too heavy, etc.). This is connected with the greater
necessity and the greater capacity for excuses. As is known, there is
nothing that would not do as an excuse for drinking: Heat and cold,
exercising and sitting still, every vocation without exception ju.stifies
indulgence in alcohol, and it is peculiar that men with academic

training as well as illiterates abate these reasons in the identical words
and adhere to them with the same faith. But in other matters also
the drunkard is distinguished by the great necessity for excuses and
the great ability in inventing them.

Hand hand with the heightened affectivity and dulness of think-
in
ing there the tendency to morbid self-reference. Even people still
is
quite well preserved take the donkey and the water in the above men-
tioned fable as a reference to themselves.
The exaggerated self-references form one of the roots of the alco-
holic suspicion, which at first is directed toward relatives and then
against all who would like to exert an elevating influence on the
patients, or who have to suffer from their doings, while on the contrary
in the society of even the most degenerate drinking companions a
complete feeling of confidence holds sway which among other things
leads to many business indiscretions. This characteristic becomes the
more dangerous as alcoholics have an exaggerated positive and also
negative suggestibility, corresponding to their affectivity. "Whoever
knows how to get in with them, can use them, as he pleases; in other
matters, especially in regard to admonitions and related things, they
are obstinate and stubborn.
The memory of alcoholics become inexact. In tests these people
do not give fewer answers than ordinary people, often more, but among
them more wrong ones. It is the same in life: often they are no
longer capable of thinking of things exactly as they are. Only in
the later stages of the severer cases there is added very gradually, as
something radically new, the memory disturbance of the organic
psychoses with its weakness for recent events. It is a sure sign of
brain atrophy and, with this, of the impossibility of complete
restoration.
This is sufficient to make liars of alcoholics. Numerous affective
causes lead them to excuses, to misrepresentations; on the other hand,
they cannot sufficiently imagine things exactly as they are. Justifica-
tion of their own and other people's acts involuntarily enter into their
thinking and the euphoric liveliness excites their ideational association
''See p. 189.
to such an extent that the necessary phantasy is never lacking, whereas
moral and intellectual criticism is suppressed during this entire time.
Female inebriates because of readily comprehensible reasons lie still
more consistently than men. How many of the lies are conscious
and how many they believe themselves for the time being cannot be
readily determined.
A large part of the psychology of alcoholics is bound up with the
peculiar attitude of the patients toward their surroundings. In spite
of all their blustering it can easily be demonstrated that alcoholics
always feel themselves to be on the defensive toward everybody who
does not drink, an attitude which even many moderate drinkers evince
in the presence of every abstainer, but which in immoderate inebriates
in time actually dominates the entire psyche, and stimulates a real
necessity for excuses and lies. They have reason to mistrust just these
decent people and those who mean well by them, and to hate and annoy
them; they are particularly sensitive and irritable in their presence,
while with bums who cannot reproach them they feel at home. Thus
they not only get into bad company and altogether away from decent
people, but they are ruined more and more by being accustomed to
intercourse with degenerate elements. Concerning the more intellectual
field it should be added that the patients cannot even dare to see things
as they are; otherwise they would appear too miserable in their own
eyes.
The attention has a limited tenacity, partly because of the lability
of interest, partly too especially because patients are more easily
fatigued The
latter shows itself everywhere, especially in their work.
In the uncomplicated cases orientation remains normal.
In severe cases perceiption also is disturbed in the same sense as in
delirium tremens, only to a lesser degree; the patients easily misread,
they mistake pictures on brief exposures, and they hear incorrectly.
Many alcoholics that have any sexual relationship show delusions
of jealousy, which are quite peculiar in form. They fluctuate up and
down in direct proportion to the amount of alcohol imbibed. In
relatively sober times it may disappear entirely, in intoxication it
becomes stronger and entirely senseless; not only chance spots on the
bed but also those on the toilet can prove the wife's faithlessness.
Illusions and memory deceptions often promote the delusion, rarely,
and almost only during inebriation it is also helped by hallucinations,
especially of sight; the husband sees that his wife winks at a man
passing on the street; he has watched her through a hole. But at
first these suppositions, produced with complete conviction,, do not
hold ground; they become uncertain or dissolve completely when one

,
wants to ascertain wliat the patient has found out for himself. Jeal-
ousy delusions often lead to murderous attacks on the wife. But
toward actual unfaithfulness many of these patients are hardly
sensitive.
Many reasons are given for the genetic explanation of the jealousy
delusions. The alcoholic loses his potency, while the libido still exists;
the marital relations are bad; the wife's love is impaired, if it has
not entirely vanished; through his absence in the saloon the husband
gives her many opportunities to be with other men; he treats her
badly and is not himself scrupulous in the matter of marital faithful-
ness. All these elements produce or increase jealousy under other
circumstances also. But between jealousy and delusion there is still
a difference that is not explained by all these reasons.

From another, though much rarer form of alcoholic delusion, origi-
nates the self -surrender to the police on the grounds of having com-
mitted some crime, usually one that was sensational at the time, rarely
one that does not exist. The patients want to confess and demand
punishment. In the cases that I could follow more closely, it was
certainly or probably alcoholism on top of schizophrenia (this is to
say, incipient alcoholic hallucinosis).
Morbid Picture. The drunkard is a man who cheers himself up,
or forgets his sad thoughts with alcohol. Gradually he takes more
and more time from other purposes, especially his work, and more
money from his family and business. He is irritated by actual or
merely probable reproaches, under certain circumstances he becomes
senselessly enraged by them, especially when he has just been drink-
ing. Later he regrets what he has done, but not deeply or for long.
and ugly scenes recur more and more frequently. He "fluctuates be-
tween unmanly weeping and dishonorable indifference" [Kraepelin)
the latter taking up the greater part of his time a carefree humor of
;
drunkards, which is easily transformed into irritability or pangs of

conscience, dominates him most frequently. In his exalted self-conceit
he believes himself to be something extraordinary, thinks he works
harder than everybody. But this overestimation does not, however,
lead to real delusions of grandeur.
More and more he forgets honor, good manners and decency; when
he speaks and acts, he does not hinder his own dignity. He discusses
the most intimate family affairs at the bar. The dignified man who
was formerly faultlessly proper finally becomes outwardly untidy, and
even loses his sense for the poor appearance of others.
In his more intimate dealings, that is. where it is not a question of
established standards, the drunkard no longer considers the rights of
others. From his wife, even when he admits a part of his faults,
he demands as her self-evident duty all consideration and love, while
he himself can do as he likes; if he conducts himself badly, it is only
the result of her lack of understanding.
He has an entirely wrong conception of his cravings it is right and ;
necessary for him to drink; it is right because he earns money (even
when the wife really supports the family) because he is the man,
because one has to have some enjoyment; it is necessary as other-
wise one cannot work. As far as he indulges in it, drinking is harm-
less; other people drink too, and still more than he. In every case
some one else is to blame, not he. If at times through some bad luck
or perhaps through special enlightenment he is in a position to judge
himself somewhat better, it only touches him in
moments of moral
dumps, an unpleasantness he seeks to remove as soon as possible
with alcohol. Hundreds and thousands of times he promises either
in all seriousness or in a hypocritical way to reform, "to be a better
man," only to break his promises just as often.
With this all he ruins his family life. The children, whom he
maltreats, are afraid of him. As a rule his financial condition suffers.
In the lower classes the wife often has to support the entire family;
the husband drinks up what he earns and extorts with threats and
maltreatment the wife's hard earned pennies, for which she has de-
prived herself of sleep. No law, much less public opinion, hinders
him in this. He is not dangerous to the public generally, he "only"
maltreats his wife, one reads in the police reports. The wife is usually
entirely at his mercy and leads a life that is worse than that of the
average slave in very different times.
The worst acts, to be sure, occur during intoxication but many
of these people do not come out of this state for days at a time.
Many of the patients get into jail intermittently. The hos-
pital gives room to only a small part. Of those who live
longer many spend their last years or decades in poorhouses and
asylums.
The female male companion
inebriate differs not a little from her
in fate. She is also much more than the latter, not
difficult to picture
only because she is less frequent, but especially because as a rule she
is much more seriously psychopathically predisposed. It then becomes
difficult to isolate what is characteristic of alcoholism in the individual
cases that are abnormal in the most different directions. To be sure,
in the psychologic examination one finds the identical abnormalities
as in men. But the attitude is different. Contrasted with the men
the female patients are taciturn at least toward the people who are
concerned with their tdcoholiism, they seek to conceal their inner

thoughts, do not admit drinking at all or only to a very moderate
degree, and when one does not believe them, they are accustomed to
make the most definite and serious protestations, even when they have
frequently been caught in the act.
This conduct, like the severer psychopathic condition, is readily
explained by the absence of the drinking compulsion in woman ; for her,
custom does not transform a vice into a virtue. She mu^t be much
more abnormal before she drinks so much (if the modern bottle beer
business maintained at the present level, it will, to be sure, diminish
is
the difference) furthermore she cannot boast of her "prowess" like

;
the man; the entire situation shows her at all times that she is doing
something that should not be done.^^
In pronounced schizoids the drinking mania and alcoholism fre-
quently show a special characteristic. Such people lead a secluded
life, and create disturbances only in the form of outbursts of irritability,
the affectivity as well as the contact with the environment remains

inadequate, even in the higher grades of alcoholism, a real ability to
discuss the mania does not exist. Nevertheless after a long sojourn
and proper treatment (consistent action
in the hospital (at least a year)
without many words, for the rest to be left alone, no irritation) will
produce an essential improvement in most cases. ^*
Course. The disease as a rule creeps in entirely unnoticed; in many
cases one cannot tell within ten years when These
it really began.
people just gradually drink a little more or they gradually become less
capable of resistance against the same quantities, and at all events the
characteristic symptom complex is only formed in the course of years.
With this all, many maintain themselves as good commonplace people
as they only need continue living at the ordinary pace, they have
nothing new to learn and need not exert themselves especially until
the more or less premature death ends all. Only a small part get
plain alcoholic dementia as a result of brain atrophy.
In this course there are often pretty strong fluctuations in part as
the result of some insight and some effort toward moderation, in part,
however, as the result of the intervention of third parties or other
change of circumstances. But on the whole there is an unchecked
decline, in many cases to the lowest human misery into which the
patients usually drag their families with them ;more favorable cases
in
the decline is only to a certain grade of feebleness which substitutes
^That description may not hold true for all American female inebriates.
^ Bills wanger, K. Ueber schizoide Alkoholiker, Zeitschrift. f. d. ges. Xeurologie,
U. Psychiatrie, 1922. Springer, Berlin.
bar-room gossip for recreation that elevates the mind and spirit, and
finally also lets it take the place of work.
Prognosis. Theoretically most alcoholics are still curable at a
time when their disease has long been obvious to the layman. Only
when in spite of energetic attempts they are no longer capable of
seeing and feeling the misery that they are bringing to themselves
and their family, or when stealthy memory defects indicate brain
atrophy or also when the innate disposition is ethically untrainable,
then the inebriate must be given up because nothing can be done for
him. To be sure, he usually has to be given up because the more
intimate or distant connections do not want to intervene at all, or
begin too late. Thus the majority of inebriates sink deeper and
deeper and are ruined after they have for decades made the family
which is tied to them unhappy in every respect; often the cause is
alcoholism itself, more frequently it is other diseases to which they

offer a diminished resistance. A small number spend their last years
in a quiet or erethic form of alcoholic brain atrophy (dementia-alco-
holico-senilis, see organic diseases). Not seldom the end is suicide,
usually during an alcoholic depression, occasionally too during some
other emotional state.
Anatomy. According to Rose the cranial bones are frequently
thickened. In the cranial cavity one often finds in the more severe
cases, that the pia is clouded and thickened; occasionally (but not
nearly so frequent as in paresis) there is also pachymeningitis hsemor-
rhagica. The brain itself in advanced cases is plainly reduced in size.
The ganglion cells show at an early stage different forms of degenera-
tion. The glia is increased as to the number of cells and fibres. The
ependyma of the fourth ventricle often shows granulations. In some
of the nerve and glia cells as well as in the walls of blood vessels, one
finds, as a rule, much fat. The organs show in different ways alcoholic
degeneration.^^
Frequency. Depending on the methods of admission in the hos-
pitals for insane, male alcoholics constitute from 10 to
the
35% of the admissions (not of the population). But this is no
measure of the distribution of alcoholism. Only a very small part
of the patients get into institutions. A degree of alcoholism, recog-
nizable on close inspection in Central Europe, is quite usual in the
second stage of maturity. one only wants to count the cases from
If
where a noticeable injury of the individual is apparent, then there
are naturally no figures at one's disposal; but whoever keeps his eyes
open will probably consider alcoholism as the most frequent disease
"'Comp. p. 303 ff.
of men, aside from cold and such triviul thin^^s. In Switzerland about
16% of the men dying between forty and sixty are desij^nated by
physicians as alcoholics. Naturally the figure is in reality much
greater. In the remaining parts of Central Europe conditions are
^
probably the same !
Causes. Hardly anywhere is as much known concerning the causes

of disease as in the case of alcoholism, and yet nowhere is there more
dispute than just here. In the first place there are two kinds of con-
genital disposition, upon which alcoholism thrives; the first represents
a disposition causing or impelling one to partake of spirituous drinks
in larger quantities, the second represents a lower degree of resistance
toward the quantity partaken of, in which case the resistance of the
brain is of especial significance for psychiatry.
The first group is Under our conditions dif-
not homogeneous.
and the weak-
ferent dispositions cultivate the active impulse to drink
ness toward the ever-present temptation and seduction. Here one
finds in the first place those with a congenital weakness of will. Others
surrender to alcohol because they have no reason for not doing so;
they are coarse and morally dull and seek momentary pleasures. Less
boon companions who fall victim to alcohol
offensive are the cheerful
in enormous numbers; most of these people not only are not psycho-
pathic, but belong to those who react to life syntonicalty, who are also
free from inner resistances and inhibitions; it is therefore absolutely
wrong to assert that only psychopaths become drinking maniacs or
alcoholics, and that they must drink because they otherwise cannot
adjust themselves to the world. Others take to drinking for the oppo-
sitereason because they are not capable of getting out of themselves or
of ridding themselves of things disagreeable in some way. Alcohol en-
ables them to forget or frees them from As mere com-
their inhibitions.
plex diseases in the psychoanalytic sense have not to my surprise seen
I
any actual alcoholics in the hospitals for the insane and in the inebriate
sanatoria. Persons having pure complexes even if they frequently
narcotize themselves in a striking manner probably do not drink con-
tinually enough to become real alcoholics. IMoreover, it is also possible
that the pronounced alcoholic, like the organic patient, loses the ability
to split off complexes. Many have some other difl5culty of adjusting
^Ônly a person who has delved into the matter can form a proper concep-
tion of the social and economic significance of alcohol. For this purpose Ger-
many spends yearly about two million marks pre-war currency little Switzerland
;
spends daily nearly a million francs, much more than the costs of mobilization.
For these sums are purchased disease, misery, crime, reduced working hours and
weakened capacity for work. Comp. Hoppc, Die Tatsachen iiber den Alcohol,
3rd Ed. Calvary, Berlin, 1904.
themselves to life; some have ambitions that are beyond their ability
and never act because they are always planning, others do too much,
but do it senselessly, the third has "nervous" troubles, etc. To this
class also belong many that suffer from mild mental diseases, in v/hom
alcoholism is not the cause but the result of the disturbance.^^ Con-
trasted with the class of weaklings we find the strong men who believe
they can stand everything and thus indulge excessively in alcohol.
Many, perhaps the greatest number of alcoholics, are the complete
victims of our drinking customs; to be sure, the latter are rarely seen
in institutions; but one sees them by chance all the more in the ordinary
walks of life and as carriers of various other diseases.
The second group, those incapable of resistance, we can describe
We only know
still less. that there are peculiar dispositions (certainly
not homogeneous ones) in which the brain reacts to the quantity of
drink imbibed in the sense of pronounced chronic alcoholism. We
cannot determine why in one, drink ruins the liver, in another the
heart, in the third the regulation of metabolism, in the fourth the brain,
in the fifth all these organs, and why many others can stand the same
quantities of alcohol fairly well without becoming alcoholics in our
sense.
Both dispositions are only exaggerations of weaknesses that human
nature generally is liable to. A craving for poison like alcohol exists
everywhere; but those races which in the course of their development
through thousands of years have had at their disposal a certain quan-
tity of this mode of gratification have adapted themselves to it; they
are temperate. But modern industry and means of communication
have nearly everywhere surpassed adaptation, hence the misery. Only
a generation ago Italy was still a temperate country; now many of
her insane asylums admit the same percentage of alcoholics as our own.
It is self-evident that it is possible that every brain could become
alcoholic, not only because we can narcotize everybody with alcohol
but because we see everywhere the identical toxic effects of alcohol.
But I doubt whether the average capacity to resist alcohol has declined
in the last centuries as many suppose.
The various dispositions manifest themselves also in heredity. In
the families of drunkards we find very diverse abnormal dispositions,
which in perhaps half of the cases become manifest as the father's
alcoholism.
Among the predisposing causes the most important is our drinking
" Ferenczi is of the opinion that alcoholism is generally a substitute for

repressed sexual desires (abstinence would then be a compensation for sexual
weakness). In reality no one lives a better sexual life than the average alcoholic,
custom, which has developed from both these dispositions witli the
assistance of our specific social conditions. This custom represents
the indulgence in alcohol as something lovely, useful, necessary, and
self-evident, so that it requires some strength to withdraw from its
influence. As a camp follower of the drinking custom, is the capital
invested in the alcohol industry whose millions have organized very
skilfully the inducements to drink. Of the well known opportunities
and seductions that come into consideration for the individual I should
like to emphasize only a few. By
mothers of spoiled sons bad company
is most often considered the criminal; but this is usually unjust because
one is rarely compelled to associate with bad company. But in refer-

ence to drinking the accusation is too often true; drinking companions
are, to begin with, so decent that the inexperienced neither notices
the evil connected with them nor can he foresee the danger that is in
store for him. One goes to these gatherings for a worthy reason, and
does not consider how unworthy a few hours or perhaps a decade later,
it may become ; it is also said that trouble and misery can be drowned
in alcohol; that is true only in exceptional cases; trouble and misery
are the results of alcohol and then, to be sure, by means of a vicious
circle they constitute an excuse to increase the evil with additional
alcohol. I know of no case where increased wages have reduced the
use of alcohol and statistics prove the opposite.
What quantities of alcohol are necessary to produce the disease
depends on the personal disposition, perhaps also on the quality of
nourishment and manner of living generally. One person may become
physically and mentally a pronounced alcoholic while perhaps one of
his companions drinks several times as much and nevertheless remains
within the so-called norm. The nimiber and strength of the inebria-
tions is immaterial. Whoever gets drunk on small quantities will
hardly ever become an alcoholic; whoever as a general thing lives
moderately will never become so, even though ever>^ year he is found
several times in the gutter. But whoever regularly imbibes larger
quantities, risks a chronic poisoning, even though he is never
intoxicated.
Differential Diagnosis. Alcoholism can be associated with ever>-
other disease and then one of the two is often overlooked. Other
symptom complexes such as paresis, schizophrenia, fever deliria. etc.,
can be tinged by alcohol. Schizophrenics, who are at the same time
inebriates, aremost frequently mistaken for mere alcoholics. If they
are sent to insane asylums, no great harm is done. The mistake is
more serious in homes for inebriates, where they usually do not know
how to handle schizophrenics, and in home cures, where the treatment
of the patients should legally and medically be entirely different from
that of mere alcoholics. Among the less noticed signs of the basic
schizophrenia the unrealistic seclusion from social intercourse is im-
portant; the inebriate who does not know what to say and withdraws
from the other patients in the institution is no mere alcoholic.
Many psychic symptoms of alcoholism resemble the paretic and
organic symptoms generally; they may
even be organic, because the
intoxication also produces a kind of brain atrophy
.^^ In older persons
the question how much of the disease is senile and how much is alco-
holic, can often not be decided on theoretic grounds.

Chronic manic patients are readily mistaken for alcoholics; more
rarely the reverse is the case. The flight of ideas, the fluctuations
of the disturbance independent of the use of alcohol, and its persistence
even in abstinence or strict moderation makes the diagnosis of mania
certain. The absence of these symptoms in spite of careful observa-
tion excludes it. Naturally the anamnesis often gives at once definite
information.
The from normal health is most diffi-
differentiation of alcoholism
cult. Regular quantities, which in Europe are considered moderate,
plainly change the appearance of the aging person; whoever has a
little practice can ascertain the same in reference to the psyche. With
us a little alcoholism, therefore, belongs to the "normal" and since a
Munich Court has decided that to drink from six to
^^ eight liters daily
is not yet immoderation, one must not imagine the "little" as being
very small. I would, thereforej have alcoholism in the sense of medical

practice begin there, where practical reasons demand it: Whoever
plainly harms himself or his family through the use of alcohol and who
cannot he made to realize this, or who no longer has the will or the
strength to better himself, must be considered an alcoholic. Among
the signs of harmfulness one naturally understands also the physical
and mental symptoms of chronic alcoholism in the psychic sense. That
this somewhat narrow, but for practical purposes valuable definitipn,
includes also the drinking mania is not only true, because drinking
mania and alcoholism condition each other, but also because practically
and legally they are a unit.
There are people, also, who, without distinct signs of alcoholism,
behave badly for other reasons, e.g., congenital disposition, and do not
manage their affairs properly; alcohol only aggravates their condition
still more. Such people must not be mistaken for alcoholics; the
prognosis and treatment are entirely different here.
" Cf. alcoholic paresis.
"Internationale Monatschrift zur Bekampfung der Trinksitten, 1897, Jahrg.
7, p. 239.
It was said that he suffers from alcoholism who regularly imbibes

alcohol before the effects of previous doses have disappeared. But
thiscannot at all be taken strictly, since in psychologic investigations
such effects can be demonstrated twenty- four hours later and even
much longer, and no one will want to designate as alcoholic one who
drinks a few glasses of beer every twenty-four hours. Then again,
he is who has a craving for alcohol and
to be considered an alcoholic
cannot resist it. But
cannot be a test, because the criterion is,
this
in the first place, the evaluation of the reasons which should restrain
from indulgence. The ordinary habitue of the saloon does not drink
as much as he does because he cannot help it, but because he knows
no reason, or cannot appreciate any, that should keep him from
doing so.
That alcoholism should be measured scientifically with a different

standard from that used in other diseases is naturally nonsense. In a
medical sense every one an alcoholic who exhibits sure signs of
is
alcoholism; whoever shows mild signs is a mild alcoholic; whoever

exhibits serious ones is a serious alcoholic. The consequences to be
inferred from this vary according to the case: practice will be infinitely
more lax than science, which cannot permit herself to be falsified by
affective or opportunistic viewpoints.
Naturally the entire affective symptom complex is not in itself
to be inferred with certainty from single symptoms, since organic dis-

eases and congenital dispositions can have a similar appearance. One
can most readily make a diagnosis from the liveliness of the reaction
in many failures, from the characteristic evasions, and from the causal
elaborations.
If one has a
time to observe the patient, then naturally his
little
reaction to abstinence is important. Patients who improve after a

few weeks in the institution, who plainly change their character for
the better and quickly get worse after indulgence, are in the main
alcoholics.
The diagnosis is very materially supported by phj'sical symptoms
and the anamnesis. But in taking the latter one has to be very careful
not only because nowhere except in sexual matters does one ever get
such false reports as in the matter of alcoholism, but also because
alcoholicswho are brought to insane asylums have not always been
psychopathies.
Erhen * states that the alcoholic tremor has the rapidity and fine-
ness of the oscillations in common with that in diabetes, nicotine
*
Diagnose der Simulation Nen'osen Symptome. Urban & Schwa rzenberg.
Berlin, Wien, 1912.
poisoning, lead, zinc, mercury, sulphuric oxide and in convalescence
after serious These tremors are more severe when the
diseases.
fingers are spread,weaker when the fingers are moderately bent; as
distinguished from paralysis agitans the fingers among themselves do
not move synchronously; in alcoholism the tongue also trembles
easily, but less so or not at all in metallic poisoning.
Care is also necessary in judging the dilation of the facial blood
vessels. There are very temperate or abstinent people who have a
red nose and only a very small fraction of inebriates can be diagnosed
in this way.
Treatment. The experience of a thousand years proves that train-
ing to moderation is a utopia. In the first place the treatment has to
solve three problems: Above all the quasi-physical dishabituation from
the need of alcohol. This is easier than is generally supposed. It is
only an exception when the alcoholic in the hospital for the insane feels
a real need of indulgence, as does the smoker for tobacco or the mor-
phinist for his alkaloid. Of the abstinence manifestations I only know
the coarse trembling. Still others are mentioned, e.g. sleeplessness,
and certainly among several dozen inebriates, one perhaps will not
sleep as much as he would like, for the first few nights in the hospital
for the insane. But in the first place there are other reasons for this;
secondly, many inebriates slept irregularly previous to this, and usually
under abstinence they not only sleep better but even normally. It is,
therefore, necessary very decidedly to advise against giving soporifics
merely because of this indication. It is just these people who must be
thoroughly rid of the habit of taking drugs for slight discomforts.
It is still supposed that the sudden deprivation of alcohol kills these
people. This is directly contrary to the facts. The omission of alco-
hol kills nobody, it is only the use of it that does. Protracted absti-
nence is not harmful; out of 279 patients discharged from the Ellikon
Sanitarium who relapsed, 62 (22%) died in the first twelve years;
of 295 cured and improved discharges 5 (1.7%) died.
Therefore the first indication is the immediate removal of the
injurious matter.
More difficult is the associative dishabituation, i.e., the breaking
of the association of ideas that incessantly impel toward drinking; in
those better disposed, it is especially hard to break the associative
identification of alcoholic indulgence with everything beautiful and
ideal that has been experienced in the past (old college men!), and
to form newer associations corresponding to realities. It is necessary
on the one hand to associate the patient's misery and those of others
with drink, and on the other hand to connect the conceptions of
THE INDIVIDUAL MENTAL DISEASES 32:5
righteousness, ability, work, and liappiness with the anti-aleohohc idea.

Still more time is needed for the training of character geruiraUy, the
habituation to regular work, the cultivation of resistance to the inces-
sant temptations, the development of self-control, of joy in real
achievement, and of pride of the right kind.
The best way to satisfy all three indications is a sanatorium which
is not just a resort for inebriates but where the patient is skiifully
treated by pedagogic and psychologic methods, and where the superin-
tendent is imbued with the lofty purpose of his cause. The patient
must and should not be accepted
persist on the average for about a year
if he does not bind himself in advance for this length of time. But
with us he can leave in spite of his pledge, if he wants to; therefore,
the superintendent must have personal influence enough to retain the
large part of the patients. Brewers, saloonkeepers and others in the
alcohol industry should only be accepted when some guarantee is
given that the business is to be transferred to some one else before the
patient leaves the institution; one cannot be an abstainer and saloon-
keeper at the same time. The hopeless, or those with a morally de-
fective disposition should be kept away from alcoholic sanatoria as
much as possible, because they endanger the cure of others.
In milder cases associations for total abstainers under good leader-
ship may suffice. But naturally they offer much fewer opportunities
and, in addition, they have the disadvantage which must not he under-
estimated, of dragging along until they are incurable, cases which in
themselves are hopeful. Where the danger of postponement is not too
great and where admission to a sanatorium for alcoholics is difficult
or impossible, one of these associations may

be tried. If one has a
choice of several associations, then, aside from the personality of the
director, that one is to be recommended that is most consistent. In
spite of the fact that the Blue Cross does a world of good, it has the
fundamental error of demanding total abstinence only from inebriates
and those who want to help them. This reduces it to a mere crutch
and makes of the patient a second rate person who is in need of one.
Whoever cannot adopt the platform, self-evident in the light of all
the facts, "that drinking causes much misery and practically no benefit,
and hence it is better for all mankind to dispense with it," such a
man is always in danger of trying, by means of drink, to elevate him-
self to the rank of superior persons. The reformed drunkard must feel
at ease in his decency and must not, like the turtle in the ball room,
get homesick for the mire.*^
"The Good Templars, the Opponents of Alcohol and, in most places, the
Catholic Abstinence League are consistent abstinence associations.
These alcoholics who lack the insight to permit themselves to be
cured willingly must be put in restraining institutions, that is, at
present, in hospitals. It is a blessing for many a drunkard if he
perpetrates something real serious or gets an attack of delirium
tremens, because then for once, he can be subjected to treatment.
Therefore, where the statutes do not make it impossible, and by way
of exception, where there is an intent to cure the patient, one should
make the most of such opportunities and recommend the hospital.
But the patient hardly gets there before a drive is made against the
"unjust" incarceration, either by himself or those like him, or by friends
disposed to moderation. Then it is necessary to stand firm. Unfortu-
nately the wife usually has the decision in her hands, i.e. the most
unsuitable person; because she is the one who has most to fear from
his revenge and who loves him or has loved him, and for that reason
is most readily deceived by the solemn protestations that appear in
quantity two or more weeks after the commitment. Then in addition,

reasons are advanced that unfortunately seem to have weight with
those not so close to the patient: "The man is not crazy at all and
therefore does not belong in the insane asylum; among the insane he
will have to become crazy; he has to be given a chance to show that
he wants to do better and can do better," etc. Thus the wife usually
weakens, even though at the time of commitment she gave solemn
assurance of her firmness. But if she can remain firm, so that the
husband never feels her doubts and if she avoids many visits as long as
he is anxious to go home instead of to an alcoholic sanatorium, then it
may still go well with those patients who are at all curable. To be
sure, as a rule after the stage of facetious euphoria and solemn prom-
ises, there is a third stage of irritation and threats to be withstood,
that gives the useful insight that the promises are in vain one has to ;
know this in order not to be frightened, because it is only a matter of

firmness to make these manifestations disappear quickly. The ordinary
threats of suicide are to be ignored.^^ After one to three months the
patients are usually transferred to a sanatorium for alcoholics. To
be sure, individual cases have to remain in the hospital for years
and, if they have sufficient endurance, they may be cured anyway.
"There are only two sensible answers to threats of suicide: either to ignore
them, that is to do the opposite of that which the threat seeks to accomplish,
or commitment to the observation ward of an insane asylum. If one acts dif-

ferently the threat becomes the worst sort of fetter that makes decent people
the weak tools of brutal rascals. It is well to think of this in the treatment of
moral defectives also. To be sure, one has to be able to take it upon oneself
that in many thousand cases one useless and harmful life may find its end on
luch an occasion.
To be sure, the hospital must be equal to its task. In many

places such patients still get alcohol, or it is made plain to them that
only for them are the benefits of alcohol injurious, or they are ^îven
positions as bartenders, etc. It may be that such institutions are
not bad in other respects, but at all events they are incapable of
curing inebriates.
Guardianship also is a palliative when properly handled. Accord-
ing to the German and much more according to the Swiss code it should
also be a factor in the cure. But as long as the majority of guardians
feel themselves closer to the inebriate than to the abstainer, naturally
not much is to be expected from this; but even now this device has a
certain benefit if the right kind of guardian is found, and with the
spread of better ideas this advantage will grow more and more if
the court of guardians has the legal means to compel a cure. Naturally
it is if the wife becomes the guardian of the inebriate.
always a mistake
As a remedy or as an auxiliary to a cure hypnotism has
principal
been recommended. It has the danger of diverting physician and
patient from the real problem. Therefore I do not use it here, although
there may be cases where it is very useful.
The chemical remedies recommended are humbug.
Whether the patient is at home or in any kind of institution, the
treatment of his environment is just as important as that of the patient
himself. That so many curable inebriates are lost is the fault of the
unfortunate patience of the wives who cannot, before it is too late,
make up minds to a measure that hurts their pride. The family

their
physician should endeavor to direct to the right place the patience
which here only does harm; furthermore he must take care that after
recovery the patient's wife remains abstinent with him.
Incurable alcoholics are a terrible burden for their families and the
community. Kraepelin recommends hospitals as a place of confine-
ment. But to me the present arrangements of the hospitals do not
seem suitable for the patients, nor do the present laws meet the scien-
tific demands. Forel and others therefore demand that special institu-
tions be arranged for them in which they are bound to earn by labor
at least as much as they need. This would have the advantage of
being a solemn warning to the attitude of the alcoholic that everyone
is powerless over him. It would obviate many crimes and other
dangers and disadvantages, and would offer the possibility of belatec
cures through protracted compulsory' abstinence and training which
might return to society after years and years many a man apparently
lost.
Strange to say in the case of alcoholism the modem physician has

to be told that the most important part of the therapy is the prophy-
laxis. But one must realize that here too only the right remedy helps:
abstaining from alcohol. It is nonsense to recommend moderation:
It is the very soil on which alcoholism flourishes. The limitation, even
the complete eradication of alcoholism is possible, if the determination
is there. There no other avoidable disease that brings so much
is
misery to civilized people. Therefore it is the physician's duty ^^ to be

informed at least as exactly in this matter as in the case of infectious
diseases. The textbook of psychiatry can only point out this duty.
There are people who are afraid of the result that a better insight
would compel them to avoid spirituous beverages themselves. To put-
it mildly, this would be no loss to the individual .physician for many ;
of his patients it would be a gain, because only the abstinent physician

can cure inebriates; for the community it would be a blessing. Who-
ever avoids abstinence in spite of insight into its benefits, because it
seems a sacrifice, lowers the medical profession which, as no other

calling, is accustomed to sacrifice life and personal advantage for the
benefit of others.
Unfortunately it is just the physicians, who in the matter of alcohol
have to make good the much harm that previous generations have
done. The theories that were advanced especially in the middle of
the last century concerning the properties of alcohol as a strength and
blood producer, as a preventative of infection and dispeller of fever,
have, it is true, been given up by science, but all the more have they
become part and parcel of common knowledge. And the charge must
be made against physicians that, though at the time they eagerly
disseminated the prejudice, they now do far too little to remove it
and, instead, still do much to support it. Every (public) prescription
of alcohol, even though in itself indicated," is harmful, partly for the
patient, partly for the community because it is irresistibly interpreted
that alcohol is beneficial or necessary for the healthy. And unfortu-
nately mistakes in practice are still being made where physicians
instigate the cured inebriate to again indulge in alcohol and thereby
lead him with his family into misfortune.
Delirium Tremens
There are several acute psychoses of a plainly specific character
based on chronic alcoholism. The most important of these is delirium
*^
The study of drinking customs and everything connected with them is
otherwise very useful also; it reveals a wonderful insight into human psychology,
especially of the power of affectivity over thought.
"Proof is, as yet, wanting that there are indications for alcohol, i.e. that it
cannot be substituted by something else.
tremens, drinker's insanity. almost only after many years

It occurs
of indulgence in alcohol; but occasionallywe have seen it in young
people in the early twenties who were addicted to drink from two to
four years; so far they have all proved to be latent schizophrenics.
Even in children and young people for whom the physician has pre-
scribed large quantities of alcohol, the delirium may break out after
a few years; but fortunately such cases are very rare.
The attack is usually precipitated by special occasions: any weak-
ening factors such as any of the acute diseases, especially those with
fever (pneumonia, exacerbations of alcoholic catarrh of the stomach,
influenza, etc.), excessive and continued drinking, or a trauma may
induce an attack. Bonhoeffer believes that the latter are less the cause
than the result of the incipient alteration of consciousness and fore-
sight; but the operating surgeon also does not fear the disease without
reason.
Abstinence from alcohol is also said to produce delirium tremens.
But very decidedly contradicted by the experience in sanatoria

this is
for alcoholics and in insane asylums, in which every alcoholic is kept
abstinent from the time of entrance. According to my experience,
and that of others, in hardly one case in a thousand does the delirium
break out, which could not have been demonstrated previously with a
fairly good anamnesis or examination on entrance, while, on the con-
trary, many cases, already clearly diagnosable, recover in spite of
abstinence. As far as I know, the individual cases cited to prove the
contrary are described and evaluated in an extremely uncritical man-
ner. Only Bonhoefjer's statement is worthy of discussion that very
frequently in the first days of confinement, especially in the case
of tramps, the delirium breaks out; but since the same deprivation of
alcohol in sanatoria does not have the same result, the difference must
lie in the other circumstances, and these are really not far to seek;
one can mention the psychical influence of confinement, the bad

.
hygienic conditions, the forbidden nourishment, the sudden deprivation

of liquids and perhaps still other factors. Have not many of these
people permitted themselves to be caught because the delirium was
already in the incipient stages? Sudden increase whiskey
in the cost of
brought with it a reduction of deliria, as did the whiskey boycott in
Breslau in 1909-10. Wigert '^^ ascertained that the suppression of the
whiskey traffic during the general strike in Stockholm was followed by
a small increase of cases of delirium tremens in Stockholm; instead of
^The frequency of delirium tremens in Stockholm during the prohibition

of alcohol, August-September, 1909, Ztschr.f. d. ges. Neur. u. Psych. 1910. I. Bd.
Orig. S. 556.
an average of 4, 6 and a maximum of 9, 16 cases came to notice in the
firstweek, one in the following week, then no more until the re-opening
of the saloons. But the author did not examine the individual cases,
so that here too it is not even proven, first, that these delirants pre-
viously had days without alcohol and, second, that the addition of
other factors (lack of work, hunger) is very probable. But if the
improbable assumption that these were cases of abstinence deliria is
to be taken as valid, it remains proven by this investigation that
abstinence deliria, even when they occur, are so rare that it would
be a mistake to consider them a factor: Among the many thousand
inebriates who were suddenly forced into abstinence in a city which
consumes 4.4 million liters of whiskey in a year, there were at the most
a dozen cases.
Sometimes, but not always, delirium tremens is preceded for weeks
or even months by premonitions: Sleep is cut short or disturbed by
terror, moroseness, irritability and uneasiness appear; the last may be
heightened to real anxiety which appears to be psychically unmoti-
vated. Occasionally dizziness occur-s. All actions are restless. The
fine tremor quickly becomes coarser: single hallucinations usually of
sight then occur, which are frequently in stable form; generally these
prodromal sensory deceptions need not have the specific character
of pronounced delirium tremens: A black dog follows the patient every
time when he comes from his morning's drink, two policemen stand
behind the closet whenever he comes home, etc. Sometimes the
hallucinations plainly betray their origin in the irritated condition of
the nerves. The patient sees shadows with high lights, he has sensa-
tions of itching or of being stabbed. These hallucinations scare the
patient, although usually they are first recognized as such until they
pass over into the hallucinations of the developed delirium.
The latter ordinarily breaks out rather suddenly at night, often
awakening in terror or even in complete sleeplessness.
Hallucinations of a very characteristic coloring are most prominent
and involve in the first place sight and touch. The visions are
multiple, movable, mostly colorless and have a tendency toward
diminutions. Furthermore, hallucinations of touch and vision both
very frequently have the character of wires, threads, water sprays and
other elongated things. Elementary visions, sparks and shadows, etc.,
are frequent. If auditory hallucinations are present, the patient most
frequently hears music (especially often with a very decided beat),
which very rare in other psychoses. At the same time one also
is
observes elementary hallucinations, especially in the form of reports

and shots, but also buzzing, roaring, hissing, etc. Words and sentences
are sometimes heard but never appear in the foreground; during the
entire course of the disease delirious patients can visually enter into
relations with hundreds of hallucinated persons that are all speechless.
Whenever auditory hallucinations formed an important component of
the morbid picture, then in our cases has so far always been a ques-
it
tion of a complication with schizophrenia. Now and then hallucina-

tions of smell and, somewhat more frequently, of taste are observed.
Not at all rare are hallucinations of the kinaesthetic sensations and
of the sensations of position. When the patients sit, they suddenly
feel the stool sway to one side, the floor moves under them; while they
are lying in bed, they believe themselves at work in a sitting or upright
position. The feeling that some seem to
real objects, that are at rest,
move probably a part of these hallucinations. Individual somatic
is
hallucinations can usually be accounted for on the basis of neuritic

parasthesias interpreted through illusions.
At the height of the pronounced delirium the hallucinations of
vision, in spite of a noticeably blurring of the coloring, are distin-
guished by great vividness and plasticity. This is particularly notice-
able in neighborhoods where on the whole descriptions of visual
experiences seem very colorless; but when alcoholics tell of their hallu-
cinations, they usually describe them with a striking vividness and
indicate the forms and movements with the hands as if they were
still seeing everything before them. "A play is performed" for the
milder patients; delirious patients always see the movies; scenes with
ballet dancers, etc., are thrown on the screen for them.
But both the distinct and indistinct visions may suddenly disappear,
especially if the patient, under a less lively concomitant hallucination
of touch, grabs in the air when he wants to seize or strike at a vision.
This gives an opportunity for all sorts of explanatory delusions. A
delirious professor took great pleasure in proving to us what a shabby
thing modern advertising is; one should just take notice, now he had
in his hand the finest advertisement which he read to us; now he
only made a motion, and everything had disappeared.
Small movable and multiple things are usually represented in
reality by small animals, like mice and insects, hence these are among
the most frequent hallucinations of alcoholics. Besides these one often
sees here also animal visions of the most various kinds; pigs, horses,
lions, camels may

appear either reduced or in life size; sometimes, too,
there may be animals "that do not exist" in exi;remely phantastic com-
binations. In entirely the same way I have noticeably often heard de-
picted on a board hallucinated on the wall, passing menageries of all
kinds of animals, usually large ones, but in some cases reduced to about
the size of a cat, which entertain the patients very well. People, too,
are frequently reduced, but they may also appear life size.
The hallucinations of the different senses readily combine; mice
and insects are not only seen but also touched when the patient grabs
them or when they crawl over his skin. Money is gathered together
and carefully placed into a hallucinated pocket. The patient sees
passing soldiers and hears the band music; he sees and hears some one
shooting at him he fights with hallucinated assailants, whom he hears
;
speak and more rarely also touches.

The optical sense deceptions of delirium tremens are livelier than
in other deliria. In moments of hallucinating, reality does not exist;
the patients take the window for the door, the stairs for the street,
and consequently are in danger of falling; instead of the wall of the
room they see the open field, bump their heads and get a mortal
meningeal hemorrhage.
Besides the hallucinations visual illusions occur in vast quantities;
those of the other senses are less frequent. The patient mistakes per-
sons and things. He misreads, often producing complete nonsense,
but frequently only inserting wrong words that have some logical con-
nections with the real text, e.g. closet instead of box, eggs instead of
butter, and similar things. It is peculiar that at times delirious pa-

tients that have read aloud disconnectedly or entirely senselessly, can,
nevertheless, later repeat the real text correctly. Hallucinations and
illusions can often be provoked and their content determined by sug-
gestion; under certain conditions both at the beginning and the end
of the delirium where spontaneous sense deceptions are not present.
One presses on the eye ball (according to Liepmann) and asks the
patient what he sees. If he sees nothing or merely elementary light
manifestation, one asks him, for instance, if he sees the dog, which is
often successful in making him believe that he perceives such an animal
and he can then describe it exactly. One hands him an unused sheet
of paper from which he usually reads disconnected nonsense but occa-
sionally also whole stories or business letters. When requested to do
so he carries on a lengthy conversation on a disconnected telephone
with a distant place. It may also happen that three hallucinating
patients who are in adjoining bath-tubs hallucinate about the same
fish which they want to catch and which jumps from one tub into the
other. Perceptions are disturbed in other respects also. The patients
very readily mistake pictures after a brief exposure, and sometimes in
this case as in reading they do it in a manner that hardly occurs else-
where; instead of the correct object, they name another which has some
relation to it but no external optical similarity. For instance, instead
of spectacles, they think they sec an opera glass; instead of a cat, a

mouse; a bird's egg is designated as a nest; a shovel as "two picks."
It is often very easily determined that paraphasic disturbances are
not involved. This shows that the "actual perception" was correct
but in its stead an overcharged associated idea comes into conscious-
ness. Frequently the color of the picture is disregarded; the green
head of cabbage in Mcggcndorfer's picture book "Nimm Mich Mit'*
is more often than not taken for a rose (moreover this is not rarely the
case with non-alcoholics also). The cucumber in the same book has
even been mistaken for a sausage.
Gregor and Roemer found in one case that perception was retarded.
Contrasted with this it is striking that a brief exposure (uncovering
and covering the picture with the hand without apparatus) in com-
plicated cases does not at all, or not materially, aggravate the result
as compared with the longer exposure.
It is self-evident thatwith the constant visual deceptions orienta-
tion as to place is disturbed severely. But this is not merely the result
of the hallucination. In the last days of a somewhat drawn-out
delirium one now and then sees orientation fail, without the presence
of an hallucination and even without a memory deception which could
explain this. Orientation as to time is also disturbed during the
duration of the delirium, in severer cases even beyond this, so that
the patients state the wrong year, etc. Often the length of the
delirium appears much greater to the patients than it really was.
Autopsy chicaUy, pure cases of delirium are oriented. They
all
know who they are, what position in the world they occupy, what
sort of family they have, where they live, etc.
Attention is profoundly disturbed. Left to themselves, the pa-
tients are occupied with their hallucinations and do not bother them-
selves much with what goes on about them. But if they are spoken
to sharply, they can be distracted. Presented before students at a
clinic they usually conduct themselves in such an orderly manner
that it is difficult to show the coarse peculiarities of conduct. It is
possible, if the attention which is constantly striving to wander is
kept awake, to make even

psychological experiments with alcoholic
delirious patients. Left to themselves they are immediately occupied
with their hallucinations. Even when they collect themselves, the
field of thought is very narrowed, consequently the ability to con-
centrate, attention, tenacity, and vigility, as well as the limits of
these are greatly reduced.
The mental stream in delirious patients has not as yet been sufl5-
ciently investigated.At all events far too few ideas are present. The
patients talk according to the momentary need, without even feeling
simple contradictions.* They are no longer capable of participating
in complicated reflections, which accounts for the marked absence of
the critical attitude as contrasted with the promptness of the answers.
It is particularly striking in the case of the senseless hallucinations.
A patient can very quietly state that somebody has chopped off his
hands and head; another patient said that he has been decapitated four
times, etc.
In contrast perhaps to all other cases of delirium and crepuscular
states they show *^ an unusually quick reaction
in conversation ex- ;
cuses, especially, are evoked with an incomprehensible rapidity, and

not alone in the matter of drinking, but in all other directions. Thus
the patients want to get away; their attention is called to the fact
that they have no trousers, whereupon they at once respond: "Yes,
that damned office boy always steals my pants; I have often told him
about it." Or his wife has taken away his shoes so that he cannot
go to the saloon, etc. Another always trembles so severely "when the
wind blows." To the question what the patient had done with his
pants, I once received the answer: "They are at home. I never wear
pants in summer."
If the delirium is complicated by epileptiform attacks or any severer
organic disturbances, this readiness may then be lacking and, on the
contrary one now observes a heaviness of perception and reaction.
Lasting delusions are rarely formed. These patients naturally
believe in their hallucinations and endeavor to explain them; but
usually the delusion vanishes with the change in the sense deception.
Most frequently the patients retain for a longer period persecutory
accompanied by anxiety. They tell how different people have
deliria
made holes in the wall and squirt water or poison through them, etc.
The memory is deeply disturbed. Even during the delirium the
patients recall only a small part of all that they have experienced;
above all the time sequence of the experience is invariably completely
disrupted (except in cases that have originated on a foundation of
schizophrenia. Here the most complicated experiences are reproduced
for several days with great clearness, and the objective control, as
far as this is possible, may be a sort of guarantee for the correctness
of the recollection). Also after the delirium, the memory as a rule is
very incomplete but by mentioning experiences one can sometimes get
;
See below among the excuses.

*"
As in perception laboratory experiment with associations shows a retarda-

*'
tion of reaction. This is probably explained by the difficulties inherent in the

experimental situation.
the patients to recall individual scenes. But even then larger or smaller
distortions are rarely lacking.
Also positive memory disturbances arc probably always combined
with delirium tremens, having the characteristics of opontaneous and
despairing confabu'ations. The patients tell a lot of things which they
have experienced neither in reality nor in hallucination, and bring
their real experiences into entirely new connections.
Recollections from the time preceding the delirium are usually good.
The affectivity has specific characteristics. In spite of the fact
that the patients always find themselves in situations not suited to
them, rarely attaining what they want (entirely similar to the dream
state), and are bothered rather than entertained by their visions, they
bear everything with an evident humor. Often they themselves feel
the silly improbabilities (impossibilities for the spectator) of their

hallucinations. They can take nothing seriously except for a moment,
they behave in this manner in the case of some clumsy treatment that
irritates them, or in the case of anxiety hallucinations that readily
lead to dangerous attacks. The majority of these patients suffer from
anxiety. And combination of anxiety with euphroic humor (grim
this
humor) is present in most cases, and does not occur in this way any-
where else.
Corresponding to the lively feelings and the lack of a critical atti-
tude there exists a marked suggestibility. One can usually talk the
patients into believing without any difficulty that yesterday they did
this and that, and were in one place or another. The easy provocation
of hallucinations has already been mentioned. The patients respond
to requests with excessive acquiescence, they stretch their legs much
too high when one wants to test the patella reflex, etc. But still other
mechanisms must assist in the production of similar manifestations.
For instance, in psychological tests one should be wârj^ of presenting
the same test units several times in the same sequence because other-
wise the patients readily answêr in the sense of this sequence. Conse-
quently there exists in contrast to the memor\^ disturbance an abnormal
capacity for habituating associations, in a direction not more exactly
known to us.
The conduct is so characteristic that the delirious alcoholic is
recognized at a distance with practical certainty. He is incessantly

restless;one can put him to bed a hundred time a day and yet he is
always out of it: the patient "is on the run." In an uncertain trembling
way something is alwâys being done pressing on real and hallucinated
;
locks, knocking the bed around, bracing against the wardrobe because
it wants to fall over, picking up money, mice and spiders are caught,
hallucinated saliva threads or hair are pulled out of the mouth and
rolled up, and other threads are spun off objects. With comical detail
the patient treads over a stretched cord, avoids wires drawn through
the air, clings to pieces of clothing, while he mistakes their different
partSj takes a sleeve for a pocket,and wants to use the shirt as a pair
of pants. He who keep it locked,
supposes people behind the door
bangs against it, calls "Open up," etc. He wants to go away, has to
go at once to a certain street, where he has important business. But
on the whole very little is said in contrast with the high degree of
motor restlessness.
Occupation deliria are frequent which may be evenly divided as to
content between business in the saloon and business in his line of
work. The coachman drives a wagon or cleans the horses, the baker
Xyj cjU ^^
^ <^

Fig. 17. Handwriting of a delirious patient. Fairly coarse, irregular tremors
and marked inequalities of pressure. The second line is more marked as the
result of fatigue.
kneads the dough and takes bread out of the oven, the carpenter planes
wood, handles boards, etc. Then again the ward is taken for a bar-
room, the orderly for a waitress; the patient orders beer; sometimes
he gets it by way of hallucination and can drink it with satisfaction.
But frequently he gets angry that nothing is brought and scolds, only
to forget his misconduct the next moment. A great many foolish
things are done; the shirt is often torn. A saloon keeper at home took
his big toe for a cork, screwed the cork-screw into it and began to
pull at it for dear life.
Severer cases remain in bed longer but have the same ideas; the bed
with its pieces of bed clothes then represents the largest part of the
environment, falsified by illusions; it is a wagon with a horse, a
carpenter's bench, etc. The patient has to catch little animals from
the bed spread; occasionally he reads entire stories which are supposed
to be on the linen.
If the weakness increases, the deliria become frothing, the patients

only make coarse tremulous movements, which are difficult to interpret,
pull at the spread or pick at the sheets. In fatal cases convulsive
movements, gnashing of teeth, etc., may also be present.
The delirious patient does not become unclean except toward the
end.
Among the physical symptoms which are never entirely lacking
but whose severity is not always in proportion to the intensity of the
psychical disturbances, the most noticeable is the coarse, irregular
tremor which is evident in all movements, as well as in speech.
The pulse is usually rapid, fluttering, irregular and, at least in
severe cases, weak. In spite of this the blood pressure
is supposed to
be increased as long as no collapse threatens. The heart weakness

is not merely a case of the chronic disturbances of the alcoholic, but
evidently of an unknown toxic substance that appears and disappears

with the deliria. In contrast with the alcoholic facial congestion the
face is usually pale and at the same time covered with sweat so that
the patients often appear markedly troubled. The urine is always
highly colored; at the height of the attack it usually contains a trace
of albumen, in some cases larger quantities and for a longer time; not
seldom some sugar is found.
The pupils often react poorly ; they may also be unequal and even
irregular. The deep reflexes are usually exaggerated ; in case of neuritis
they are naturally diminished; on admission to the hospital they are
often still lively, on the following day diminished or absent.
The temperature, even when no complications are present, is
usually somewhat high; in rare cases it rises to over 140 F. so that

the patients die of hyperpyrexia (Delirium tremens febrile).
Typical epileptiform attacks may initiate or accompany the
delirium; usually they are single attacks.
Sometimes there are evident signs of neuritis or at least neuritic
thus one can elicit pain through pressure over the nerve
irritations,
trunks and muscles, there may also be weakness and even pareses.
I have frequently observed inflammation of the optic nerve; also
central organic signs such as disturbances of coordination or cerebellar
ataxia; but they are often difficult to see on account of the marked
tremor. In many cases there is a complete analgesia which is often
very unpleasant especially in surgical cases: The patients want to
walk about when their legs have been recently amputated or
their bones broken, they tear off their bandages and dig into their
wounds.
At the height of the attack sleep is entirely absent or is, at any
;

rate, very brief. Moreover the excitements are invariably severer
at night than during the day.
Course. The disease usually runs a course from two to four days
and ends in recovery, often following a usually very long, critical sleep
in other cases recovery comes gradually. I have not seen a delirium
tremens last longer than fourteen days. The slower the recovery
proceeds, themore probably are organic disturbances in the sense of
Korsakoff connected with it. Deliria, which are further protracted
into the second week, are probably always complicated; this is espe-
cially true (if those in which after improvement a sort of relapse occurs.
If the disease runs its typical course, the hallucinations gradually
become more and more blurred and less numerous. Often, however,
they at first lose the value of reality ; the birds are no longer alive but
stuffed, the scenes are especially performed and finally are thrown on
the screen only optically as by a magic lantern.
if
Perhaps in between one and two percent of the uncomplicated

cases the patients die of heart failure. Moreover the initial diseases
(pneumonia with pus, etc.) may naturally end fatally. The mortality
statistics from different places are not comparable because, depending
on conditions of admission, some institutions admit mainly complicated
or mainly uncomplicated cases. But there are statistics in which the
fatalities still reach 26 percent. I cannot account for this in any other
way than by supposing that mistakes were made in the treatment.
After the delirium there naturally remains the chronic alcoholism.
The anatomical findings justify the assumption that in every alcoholic
delirium some components of the brain are destroyed. In severer cases
the delirium is followed by alcoholic feeble-mindedness or Korsakoff's
disease. Some delusions may persist for a longer time until they are
forgotten rather than corrected. According to some, "alcoholic para-
noia" and chronic hallucinoses may become superimposed.
The attack of delirium tremens may recur; in the course of several
years the same patient may pass through a dozen or more deliria. But
such people who relapse several times invariably become very
demented.
Besides the typical cases there are abortive ones which show only
few symptoms, such as very slight confusion and marked tremors
or a few hallucinations. They pass away completely in one or two
days. Then there are deliria which from the very beginning show a
chronic character. The patients usually remain oriented, hallucinate
almost only at night, even then not always, and sleep in between times;
during the day they can, under certain conditions, even perform simpler
tasks. Such deliria can last four weeks and are to be differentiated
from the fully developed attacks in which a complication with Korsa-

koff's disease is responsible for a protracted convalescence.
In schizophrenics, delirium tremens is somewhat modified. The
deliria often expose complexes. Auditory hallucinations are promi-
nent (somatic hallucinations are, as far as my experience goes, not
exactly frequent). But above all the deliria are more connected j for
days the patients experience complicated scenes.
Such a patient very dramatically described his experiences ir
prison and in the insane asylum in thirty-six pages: "What I suddenh

had to see there, made my hair stand on end. Forests, rivers, ocean^
with every kind of dreadful animal and human figure, which no human
eye ever saw before, whirled by incessantly, changing off with the
work shops which horrible spirit figures were working.
of all callings, in
At both sides the walls were nothing but a single ocean with
thousands of little ships on it; the passengers were all naked men and
women who indulged themselves to the tempo of music, whereat every
time a pair had satisfied themselves a figure stabbed them from behind
with a long spear so that the ocean was colored blood red; but fresh
droves always came. ... A train from which many people alighted.
Among these I heard the voices of my father and my sister K. who
came to deliver me. I plainly heard them converse with each other.
Then I heard my sister whisper again with an old woman; I called
to her for dear life to deliver me. She called that she would do
. . .
it but the old woman did not let her go, warning my sister that thereby
she would bring misfortune on the entire household, but that nothing
was happening to me. .Amid prayerful tears I awaited my death.
. .
The silence of the grave prevailed and spirit figures surrounded me in

droves; at last one of the spirits came and held his watch in front
of my eyes at a certain distance merely indicating to me that it was
not yet three o'clock as none of the figures were permitted to speak."
Then there were long negotiations among the relatives of the patient
who wanted to ransom him, at first with smaller sums, then with larger
ones. Other voices debated how they would do away with the patient.
Then the relatives w^re induced to go on ladders and thrown
into the castle mote where they were heard crying and choking. The
wife of the jailer came, cut off his flesh piece by piece, beginning at
his feet and going up to his breast, fried and ate it. She poured salt
on his wounds. On a wildly swaying scaffold the patient was drawn into
the various heavens up to the eighth, past choruses of trumpets, who
proclaimed his fame. At last because of some terror he was again
consigned to earth. . People sat at a table and at and drank
. .
things with the most marvelous aroma but a glass was handed to him,
;
it disappeared into nothing and he suffered great thirst. Thereupon
he had to count and figure out loud for hours (objectively: verbigera-
tion) In a little flask a divine drink was handed to him but when he
. ;
wanted to take it, it broke and the content flowed between his fingers
like threads of glue. Later a great battle was fought between his tor-
mentors and his relatives of which he saw nothing but heard blows
and groans, etc. Then scorpions came, drawn on long threads. During
the entire journey to the institution, which was also not recognized
by the patient, his sister sat on the roof of the wagon and always
cried out the same words. In the institution was a man who always
squirted him with urine so that the patient had to freeze severely.
Anatomy. As a sign of the poisoning one finds throughout the entire
brain diseased and degenerating ganglia cells and fibres, which are
not, however, evenly distributed. The fibres are said to degenerate
in largenumbers especially in the motor centres and in the cerebellum.
Punctiform hemorrhages are frequently seen and belong to the degen-
eration of the blood vessels. As a result of death from heart failure
there is also a venous congestion of the entire cranial content.
Naturally the clinical signs of chronic alcoholism are found in the brain
and the other organs. The sclerosis and discoloration of the heart
muscles probably connected with the acute disease.
is
The causes were mentioned at the beginning. Protracted drinking

must have prepared the ground, and the disease afflicts chiefly, even
though perhaps not entirely, drunkards who indulge in whiskey, either
exclusively, or in addition to other alcoholic liquors.
The most frequent age for the disease is accordingly between
thirty and fifty, and the maximum is closer to the latter figure than
the former, many cases even occurring after fifty.
The pathology of delirium tremens is still entirely obscure. To be
sure, it is not a question of direct alcoholic poisoning, but of a toxin
(apparently clinical), which in consequence of a protracted indulgence
in alcohol in the case of a definite personal disposition, is set free as a
At all events not only is the nervous
result of fortuitous impairments.
system poisoned but also the heart and perhaps also the kidneys,
and other organs.
The character of the hallucinations is fully explained by the irri-
tating states of the optical and tactile apparatus. The slight participa-
tion also of the psyche indicates a more peripheral origin of the sense
deceptions. Complex hallucinations are very rarely involved. If most
of the sensory^ disturbances are auxilliary to the complexes, complica-
tions with schizophrenia may with great probability be inferred.
In most cases the patients are hardly or not at all participating spec-
tators of their hallucinations, or they conceive of the annoyances that

the animals cause them as comical misfortunes.
Only the anxious hallucinations have a different significance. They
are evidently the expression of the somatic fear, caused by weakness
and perhaps also directly by the poisoning, the anxiety
of the heart
expressing as in a dream or in fever by hallucinations.
itself The
accompanying euphoria and the ready humor are a part of chronic
alcoholism.
The diagnosis is usually very easy. The following points are to
be considered: In the first place, the entire appearance, which one
must have had an opportunity to see; then the anamnesis, in which,
moreover, the drinking is sometimes denied in every way ; the phj^sical
signs of alcoholism, the coarse tremor; the type of hallucinations, a
combination of visual and tactile; in both fields one frequently finds
threadlike structures; in the visual field the hallucinations are multiple,
moveable, and colorless, manifesting themselves especially in the form
of animals with a tendency to dimunitiveness ; the retention of auto-
psychic orientation; the promptness of the psychical reactions; the
(relative) capacity of being aroused from the delirium; the scarcity
of complex contents, and the intermingling of humor and anxiety.
As far as I have seen, the fever deliria, that are so often mistaken
for delirium tremens, are invariably complex deliria in which the rapid
reaction is lacking. But there are many kinds of fever deliria, and
psychiatry does not as yet know them all.
important to note that because of accompanying alcoholism

It is
any other conditions may obtain "alcoholic coloring." The connected
hallucinations of schizophrenics which are also visually especially
plastic have been mentioned above. Living visions, etc., mingle with
other morbid pictures, e.g. in epileptic twilight states.
Treatment. Unfortunately delirium tremens usually must be
treated at home or in the general hospital. But the physician must
not forget that to cure the alcoholism at the same time wôuld only
be possible if the patient is brought to a suitable hospital for the
insane.
The prime condition of a proper treatment is supervision. The
patients can very readily do harm. In the first place, because they
hallucinate differently than any one else ;
*^ or they consider themselves
attacked or insulted; they are jealous of their wife and resort to
weapons; or they handle weapons in such a manner that they acci-
dentally injure themselves or others. One of our patients jumped into
the manure hole to hide from the animals. In surgical cases the
*"
Comp. p. 328.
analgesias constitute the most serious danger. The orderlies should try
to keep the patients in bed. To be sure they always get out again
but if they are permitted to wander at will in a room not specially
adapted, too much damage may readily be done. If the patient be-
comes weaker, he kept in bed more easily fortunately so, because
is
just at that time the stay in bed conserves the strength. The incessantly
repeated request that they remain in bed and go to bed is an excellent
means of diverting them that does not irritatemuch. Instead of the
bed the tepid bath is often recommended. This is naturally also a
good place for the patient to stay; but it is questionable whether by
itself it shortens the delirium or has a quieting influence. With proper
treatment the patient is violent only in exceptional cases; to be sure
he may tear his shirt, damage the door, etc. It only comes to a real
fight in case of clumsiness or impatience on the part of the attendants,
or in case of severe anxiety hallucinations; but these too are amenable
to quieting influences.
The second important point is the nourishment. The patients are
near a collapse, the heart is poisoned, the urine is too scanty, the
functioning of the stomach is disturbed by the catarrhal condition;
the patients do not take the time to eat, or refuse nourishment because
they fear they will be poisoned. All these indications call for a milk
diet, which needs not be exclusively so, except in case of complicated
cirrhosis of the liver or nephritis. One should offer the patient milk
in addition to the ordinary foods, from one to several quarts a day.
Since they are used to swallowing fluids, a drink is the easiest thing
to get them to take; the milk is same time nourishing and
at the
relatively easy to digest. It promotes somewhat diuresis and thus
probably has the effect of tending to rid the organism of poison.
Everything else is secondary. In a private home one will usually
be compelled to give hypnotics. They do little good, probably not at
all, until the crisis is passed, which practically means when they are
no longer necessary; to be sure, one can perhaps at this time induce
the critical sleep a few hours earlier. Chloral, sulfonal, trional,
methylal, amylene hydrate, and paraldehyde are used, of which espe-
cially the last is to be recommended.
For the threatened collapse cardiac stimulants are also given. If I
found this necessary, I would, e.g., prescribe digalin.
The question has been much discussed whether alcohol should be
given. It is certain that since the larger quantities of alcohol have
been dispensed with, the mortality has decreased greatly; if one really
did help individual patients with alcohol, a greater number would be
killed by it. Consequently in more recent times delirium tremens is
,
treated without alcohol. But it is not to be denied that at times one

of the severer cases, which with us are to be seen only in people that
come from East Europe, might be carried through the crisis by alcohol.
In a single case that I observed myself, I can interpret the result in
that way. In other cases where I permitted myself to be influenced
by relatives or other circumstances, no benefit but probably harm could
be noted. But I assume that only the larger doses, which nowadays

are hardly ever used, are directly dangerous. // one feels compelled to
give alcohol, the taste should be disguised as the patient will other-
wise carry over into the chronic alcoholism the professional sanction
of his conviction that the stimulus is necessary for him}^
Alcoholic Hallucinosis
(Kraepelin's hallucinatory insanity of drunkards)
(Wernicke's acute hallucinosis of drunkards)
Alcoholic insanity is in many respects the opposite of delirium

tremens. It manifests itself chiefly in auditory hallucinations, which
have a peculiar character: In most patients it is a case of the voices
of several or many people not present who discuss the patient in a
dramatically elaborate dialogue; that they discuss him in the third
is,
person; much more rarely do theyspeak to him.^ These voices

threaten him, remind him of his sins, scold him, make plans as to
how they will catch him and perhaps torment and torture his family
also. Some egg the other on, or some of them side with the patient,
try to defend him and save him. In very acute cases the connection
isusually less organized; in place of more quiet scenes there is a con-
fusion of voices. Sometimes the voices are rhythmic, partly s^'n-
chronous with the pulse, and partly with an external sound, e.g. the
ticking of a watch, as "You are a fool, you are a fool" [Bonhoeifer)
or they take the form of rhymes and satiric verses about the patient.
Frequently the patients hear their own thoughts or answers to them,
or one ascertains what they are doing or criticizes their actions.
Besides, especially in the beginning, one seldom fails to note sounds,
such as buzzing, snapping of gun triggers, striking of rifle bullets,
cracking, and sounds of horses' hoofs, all of which is related to the

patient.
For prescriptions see p. 223.

*
However, even in the most pronounced cases, it is also quite usual for the
""
patients to try to communicate with those hallucinated persons who take their
part, and to obtain answere from them.
Of the hallucinations of the other senses visual deceptions occur
most readily, one of the acting persons is seen behind a door or some-
where in the dark. Visions similar to those in delirium tremens may
also appear intermingled with the others. Skin sensations, being
squirted at, or blown at, are also said to occur; hallucinations of smell,
taste, and especially somatic hallucinations, probably belong to a
fundamental schizophrenia.
Delusions of persecution correspond to the hallucinations. There
are people present who mock the patient, punish him, want to do away
with him, and under certain conditions there are also some who take
his part. Usually the patient does not feel entirely innocent; besides
enormous and unjust accusations, real mistakes are held against him,
among others, e.g., his drinking; but everything is exaggerated. Invari-
ably there are delusions of reference, this or that real person, but
especially this or that event, being brought into connection with the
machinations against the patient. Isolated ideas of grandeur are very
rare. The delusions do not constitute a compact, carefully thought out
picture, the patients are just being persecuted by a gang; but the
improbabilities are not noticed, much less explained. To be sure, at
times there an explanation. Their enemies have machines, with
is
which they listen in on the patients and through which they speak to
them; they want to poison them in some way. Supernatural accom-
plices, such as God, angels, devil, hardly ever occur.
At the same time the patients remain oriented and in spite
of the delusions they generally remain clear. They do not mis-
take the real environment into which they put the hallucinatory
experiences.
Attention appears to be nearly normal; one can carry on a sys-
tematic conversation with the patients; to be sure they are easily
diverted by the voices. Normal thinking, as far as it can be tested,
appears not to be changed outside of the delusions.
The dominant affect is anxiety, which is not lacking in any case
and usually dominates the whole behavior, which at most only tem-
porarily corresponds to the situation which subjectively is often
altogether desperate. The patients are relatively indifferent, often
resigned to their fate ; or, instead of defending themselves, they go to
the police and demand the punishment of their persecutors. I cannot
decide whether this incomplete reaction an expression of the super-
is
ficiality characteristic of drunkards, or whether there does exist any-

where a consciousness of the unreality of the experiences. At all events
in a large number of cases as in delirium tremens the alcoholic humor

remains at the same time with the anxiety. In spite of this suicide
is not rare, especially in the first stage. In cases taking a chronic
course irritability also appears; but I have not seen real outbursts
of violence.
The suggestibility so pronounced in delirium tremens is wanting
here, at least in regard to the hallucinations. The patients do not
let themselves be diverted from anything; on the contrary, they feel
the necessity of proving their ideas to others.
Memory is in all cases good, even better than could be expected
in the confusing variety of experiences. During the disease and after
it the patients can recount a number of details in an orderly manner.
Confabulation is rare.
The behavior of the patients is to all appearances proper; whatever
strange thing they do is a defense against supposed attacks. In all
other respects they retain their composure. Many even travel about,
to evade their enemies, when to be sure they may barricade their room
in the hotel. In the asylum they submit to the regulations as far
as they are not preventedby the hallucinations. The physician
is recognized as such, and does not belong to the enemies, and the
hallucinated scenes are, in contrast with delirium tremens, outside of
the room in which the patient is situated. Bonhoeffer actually speaks
of a "clear-minded delirium."
The physical symptoms are insignificant. It is a striking fact that
the symptoms of the basic chronic alcoholism are sometimes not visible
on the average far less pronounced than
at all; at all events, they are
in all other alcoholic diseases.In very acute cases, which in other
respects also have a tendency to mingle with delirious symptoms,
coarse tremors and similar signs of alcohol may also be present.
Sleep is invariably disturbed but hardly ever entirely lacking as in
delirium tremens.
Course. Alcoholic insanity usually breaks out very acutely; pre-
monitory signs need not have preceded but ma}" be present in forms
similar to those in delirium tremens, the hallucinations always appear
rather as noises than as visual deceptions, in addition there may be
anxiety, and irritation; furtive transition of the prodromal symptoms
into the real delirium in the course of a few days or even weeks occurs
only rarely. The outcome is probably always by lysis, it may be after
a few days or after months.
Repeated attacks in the same patient are not rare.
As a rule the disease passes over into recovery. Korsakoff's syn-
drome never follows typical alcoholic hallucinosis. It is a question
whether the delusions and hallucinations can continue to exist in a
chronic form. At all events it rarely occurs, except when there existed
previously a paranoid or otherwise a latent schizophrenia.
According to the course one can distinguish with Kraepelin an
acute and a subacute form, the former of which lasts from several days
to several months, the latter about two or three months. But transi-
tional forms are not rare. The two types are also plainly differentiated
symptomologically ; in the subacute form every indication of confusion
is usually lacking; the hallucinated scenes are in this case elaborated
to the greatest extent and may be carried on for months in a very
consistent and unified manner. The remaining alcoholic signs are
very apt to be lacking here. On the contrary, in the acute cases the
alcoholism is more pronounced; even coarse tremors and gastric symp-
toms also are not so rare. The voices are more confused, more peculiar,
fragmentary, and speak to the patient oftener, e.g. in case of denuncia-
tions; here the rhythmic expressions and repetitions occur, and finally
only mixtures with delirium tremens symptoms are present which may
predominate to such an extent that one cannot tell to which disease
the case should be ascribed.
Thus the symptom picture of alcoholic hallucinosis is much more
changeable than that of delirium tremens. The cases taking a slow
course behave themselves outwardly in an orderly manner so far as
they do not react to the delusions ; they can run about without being
at once conspicuous. But anxious restlessness, defensive measures, or
stories of persecutions easily betray the patient. The most acute are
so dominated by their delusions and hallucinations that they take too
little consideration of their surroundings and on superficial inspection
appear confused without being so.
The disease is not frequent and, disregarding the different classifi-

cations of psychosis in different places, occurs rather irregularly.
According to Kraepelin the proportion to delirium tremens is 1 to 3,
according to Schroeder, (Breslau), 1 to 20, with us in Switzerland
about 1 to 44.
According to Kraepelin alcoholic hallucinosis afflicts women
relatively frequently.
The age of the patients is on the average less than in delirium
tremens, according to Schroeder between 30 and 35 years.
The cauê and pathology are still entirely unclear.
In cases with the ordinary sub-acute course which I have seen
so far, I could always demonstrate with certainty or great probability
that besides the alcoholism a long standing schizophrenia was present.
The (rare) acute attacks in my experience were all at least a little
abnormal in the direction of schizophrenia, although the connection

herewas less plainly pronounced.'"''
The differential diagnosis of alcoholic hallucinosis as such is usually
very easy. As a anamnesis alone points to the disease, but
rule the
the diagnosis is further confirmed by the vivid and connected hallucina-
tions. I know of no psychosis with dramatically connected and
elaborated auditory hallucinations, which speak of the patient in the

third person, in which there is no alcoholism. Also the particular
vividness of the hallucinations with persistent clearness and orientation
indicates the alcohoHc coloring with certainty. The only difficult
question is whether a pronounced schizophrenia is in back of it. Where
neither in the anamnesis nor in the picture itself pronounced schizo-
phrenic indications are found (lively somatic hallucinations, affective
disturbances), the prognosis should not be considered bad, even when
the schizophrenia is certain; the latter is very rarely subject to an
exacerbation during the insanity.
Treatment. Because the patients, at least in the beginning, are
very strongly inclined to suicide, and during the entire course are very
burdensome, treatment in an institution is nearly always indicated.
Under favorable circumstances the alcoholism can then be treated
at the same time.
Alcoholic Psychoses with Organic Symptoms

Even delirium tremens is a distinct poisoning of the nervous system
with indications of peripheral neuritis, frequent organically conditioned
eye symptoms, and acute alteration of nervous elements in the brain.
However, here the psychic manifestations predominate and they are
apparently more the expression of a functional poisoning of the central
nervous system than of the slight destruction in it. In contrast to
this are the purely alcoholic neuritis and the (rare) alcoholic myelitis,
where only an anatomic disturbance seems to be present and where,
at the same time, the psyche remains entirely or almost entirely intact.
Now the acute injury to the tissue may
chiefly afflict the brain or it-
may be localized only in the brain, and we then deal with a Korsakoff
psychosis, the main characteristic of which is the organic symptom
complex, usually combined with neuritic manifestations. In other
cases the process, besides being localized in the cortex, is also localized
in the centers that control the inner eye muscles and speech coordina-
^ Alcoholic hallucinosis could therefore be a mere syndrome of schizophrenia

induced by alcohol. This would be borne out by the circumstance, that under
other conditions the generally disjointed auditory hallucinations of schizophrenics
readily become connected through indulgence in alcohol.
tion, which produces a picture similar to paresis, or alcoholic pseudo-
paresis. Between these borderline cases, distinguished as types, there
are all kinds of transitions and mixtures, and the number of the com-
binations is further increased by the fact that such processes may also
be chronic or sub-acute; this is especially true of the degeneration
of the cutaneous nerves and the rheumatoid pains which regularly take
an entirely chronic course. Neuritis in individual nerves, especially in
the peronei, may begin in sub-acute form; also psychoses of the
Korsakoff variety, and still more frequently of the pseudoparesis
variety may take months for their development. To be sure there
are also mild, "abortive" cases.
In reality we therefore meet all kinds of combinations of chronic
and acute neuritis, and cerebral organic and toxic manifestations (the
organic syndrome corresponds to the organic-cerebral processes; the
delirium tremens syndrome corresponds to the toxic-functional proc-
ess) the entirely pure cases are not even the more frequent, but as
;
a rule one of the syndromes stands in the foreground. Delirium tremens

is especially often connected with the diseases having an acute onset;
they may be neuritic or pseudoparalytic or of the Korsakoff variety.

The division of the acute forms into delirium tremens, Korsakoff,
pseudoparesis, polioencephalitis superior does not therefore presuppose
a distinct and fundamental separation. It is not yet known whether
differences in the localization, intensity, and the time of development
are due to the influence of the identical poison, or whether they are
due to combinations of different poisons.
On the more neurological side two forms are conspicuous that must
be mentioned: The internal and even the external eye-mv^cles may be
especially severely affected. The cases that I have seen ran their course
with a somewhat protracted and not very pronounced delirium tremens.

They healed in several weeks or months. Then Charcot distinguished
the (two sided) alcoholic neuritis of the peronei with paralysis of the
anterior foot muscles and consequent sinking of the points of the feet
(steppage gait). It seems to occur chiefly in those that drink the
higher grades of liquors.
The Alcoholic Korsakoff Psychosis {Chronic alcoholic delirium
according to Kiefer and Bonhoeffer).
The Korsakoff psychosis ^^ in the majority of cases begins with a
delirium tremens that recedes somewhat slowly and leaves behind the
organic syndrome. It does not correspond with the facts to designate
only the "amnestic symptom complex" as the characteristic feature;
all other organic symptoms belong to it.
^See p. 230.
Nevertheless the memory defect is in the foreground. In pronounced

cases the patients forget from one moment to another what they have
experienced; at every visit they tell and ask for the same things. But
sometimes single elements, especially confabulated ones, are retained
for a long time. In most cases at the beginning there is a plain bound-
ary line at the period of the onset of the disease in which what
happened previously is still remembered. But the line is usually
blurred in time; as in other organic diseases the memory defect can
finally extend back very far. For example, some live again in the time
of their military service and, with the exception of smaller islands,
have forgotten what happened after. Only when the disease has
improved a little do the patients sometimes notice the memory defect
and endeavor to help themselves with memoranda. Previously they
conceal it from themselves with the most flourishing confabulations;
they never appear at a loss for words, narrate spontaneously, and on
occasion, all sorts of invented experiences, usually such as are still
conceivable.
The general opinions which the patients have formed in the course
of their lives are not lost, neither are the simpler acquired aptitudes,
etc. In the ordinary cases, also, the patients have no diflBculty in
finding words.
In the beginning the mood is usually alcoholic-euphoric; after
months or years it change in various directions and become morose
may
or indifferent. In other respects the affectivity is very labile and
easily stimulated in all directions.
Orientation is disturbed to a high degree. The patients no longer
have any conception of time relations and as to location, also, they
only get along somewhat after a longer time. In spite of this the
patients move about entirely free from care, because they do not
notice their deficiency.
The apperception of sense impressions is retarded and is readily
falsified.
Active attention seems very good in conversation; the passive is
reduced.
patients tire very easily of all mental exertions.
The
In the beginning the patients are fairly active; but they retire
more and more, and their initiative, as well as their interest in their
surroundings and sometimes even in their own welfare, declines.
There are also somnolent and stuporous cases, usually as a result
of more severe organic affection, especially in the region of the corpora
quadrigemini.
On the whole only the symptoms of deficiency become chronic
(such as the organic dementia, and not the delirium, the stupor, etc.),
but now and then one on states of confusion, and
also finds later
especially individual passing, or more protracted, but not elaborated,
delusions, preferably those of being robbed or persecuted, and at
times also a grandiose idea. In patients that are quite demented these
delusions as well as the confabulations may
appear senseless; the
patient is "Emperor of Rothschild" In a few cases I
(Schroeder).
have seen pictures of a schizophrenic variety following later, but
these patients were previously already abnormal, so that it was prob-
ably a case of a combination of alcoholic Korsakoff and schizophrenia.
The physical symptoms, aside from the signs of chronic alcoholism,
are those of a general neuritis, thus we have: pains, paralyses,
atrophies, contractures of the muscles of the eyes, of the vagus region,
of the nerves of deglutition, and more rarely of the bladder and colon.
During the delirious stage sleep is naturally disturbed; afterwards it
is usually normal.
In the beginning the metabolism is usually disturbed. In the
chronic stage it is normal, or the patients actually weigh more than
before.
Frequently, especially in the beginning of the course, epileptiform
attacks are found.
Course and prognosis. Ordinarily there are premonitions of the
disease, which are the same as in delirium tremens. The delirium
then breaks out, usually with a pronounced tremens character; in
single cases it takes other forms also. With slow fluctuations it sub-
sides, leaving behind the simple Korsakoff. Rarely, there is a chronic
development that takes several months or even more than a year. Such
cases, too, may improve decidedly or even recover.
The stuporous form is probably always acute.
In the course of about a year, sometimes a little longer, sometimes
sooner, a part of the manifestations invariably disappear but least of
all the affective disturbance. In some cases the recovery reaches as
far as complete ability to work and practical rehabilitation. But
most of the patients remain more or less organically demented even
though they can be used in the institution for many tasks
The neuritic manifestations disappear much more frequently,
sometimes with remarkable rapidity. But at times atrophies of indi-
vidual muscle groups persist.
Some patients die in the acute stage, in part from weakness of the
heart, in part from paralysis of the vagus or from choking and similar
accidents.
Anatomy. Anatomically one finds as the sign of the Korsakoff
psychosis a diffuse disintegration of nervous elements in the brain; in

severer cases this is connected with an inflammatory reaction of
smaller vessels that form offshoots and whose cells proliferate. Other
vascular changes occur also, e.g. hyaline degenerations. As a result
of the vascular disease one notes numerous small hemorrhages.
Besides these one naturally finds also the disturbances of chronic
alcoholism.
Pathology, and cause. Compared with the more functional
delirium tremens the anatomically conditioned Korsakoff is the severer
disease. It also appears a little later, chiefly in the forties or fifties.
It is striking that relatively it afflicts the female sex severely; accord-

ing to Chotzen there is one case of Korsakoff to about twenty cases
of male delirium tremens, but only two female cases. With our condi-
tions the difference is still greater in that Korsakoff among men is
decidedly rarer. It has also been noticed that infectious diseases,
marasmus, higher grades of alcoholism, seem to favor the disease, and
that it frequently appears after repeated delirium tremens, which
indicates that a poor resistance of the nervous system is a concomitant
factor in the disease. But one can also think of the kind of poison;
of the women that I saw, most or all consumed cordials, and it is known
that the essences of the liquor can cause neuritis.
The differential diagnosis is usually easy. Even during the initial
delirium tremens one usually notices a reduced ability to be aroused,
the absence of quick reaction, and a difficulty in grasping simpler
questions which does not readily occur in the simple delirium.
Compared with the other organic diseases the course is important,
in so far as it shows on the one side improvement with abstinence, on
the other side progressive dementia, even though there be fluctuations;
then, too, the delusions and confabulations only rarely become senseless.
Against paresis is the negative spinal-Wassermann. It becomes impos-
sible to keep apart the influence of the different causes, when arterio-
sclerosis or old age contribute to cerebral changes. As against the
Korsakoff-like complex in head trauma, it is to be noted that usually
the latter begins in an acute form and improves quickly or heals,
whereas the trauma may also be the result of the incipient Korsakoff.
An exact anamnesis is therefore of special importance.
Treatment. A lasting deprivation of the responsible poison is
naturally necessary and this can almost only be achieved in a hos-
pital. Moreover, the excitement at the beginning, and then especially
the disturbance of orientation and memory, which make the patient
incapable of taking care of himself properly, usually necessitate treat-
ment in a custodial institution. After partial improvement some cases
can be cared for in public almshouses, but the tendency to alcoholic
indulgence remains which readily causes new shifts.
Alcoiholic Pseudoparesis.
As alcoholic pseudoparesis we designate a Korsakoff V^^hich as a

result of special localization imitates the physical signs of paresis,
especially the pupilary and speech disturbances. The differential
diagnosis from paresis enters into consideration especially when the
patients are brought to the hospital because of delirium tremens and
the organic symptom complex remains after the delirium has passed
away. In most cases, probably always, the flourishing ideas of
grandeur are lacking in pseudoparesis. Real manic states probably
do not belong to it; the continued progress of the disease in the
institution speaks for paresis; however, in the beginning of the dis-
turbance only the spinal Wassermann can definitely decide the
differential diagnosis. Alcoholic paresis may improve and in some
cases the recovery may be complete.
Kraepelin designates as "alcoholic paresis" the simple combination
of paresis with alcoholic symptoms, especially the hallucinations of
delirium tremens. Others use the expression in the sense of alcoholic
pseudoparesis.
Probably because the concept of paresis has become clearer we
have not seen for ten years any disease that we could designate as
alcoholic pseudoparesis.
Polioencephalitis Superior.
The encephalitic changes, even in the ordinary Korsakoff, show a

certain preference for localizing themselves around the third and fourth
ventricles, from the caudate body to the anterior part of the red
nucleus, especially in the nuclei of the eye muscle nerves. In some
cases a hemorrhagic encephalitis of this region constitutes the sole
or, at least, the chief disturbance. The corresponding morbid picture
belongs rather to the pathology of the brain than to psychiatry.
Nevertheless these cases not seldom get into insane asylums because
in the beginning they are confused and at times somnolent and coma-
tose. Paralysis of the external, and occasionally of the internal eye
muscles is especially noticeable, and at the end of the first week or in
the second the patients usually succumb to general paralysis. Some
cases remain alive and may then recover or go over into a symptom
picture similar to Korsakoff. It is difficult to designate it from
encephalitis lethargica.
;
Alcoholic Leukencephalitis of the Corpus Callosum
Marchiafava and his pupils have described an alcoholic disease in

which the fibres of the inner two thirds of the corpus callosum in their
entire extent disintegrate after a while. Other brain localities also,
especially the anterior commissure, may also be slightly affected. In
Korsakoff, similar processes are said to have been found occasionally,
so that here too, perhaps, there may be nothing new.
But the and results in death in from
affliction is rather chronic
two to six years; first a gradual organic dementia appears, often

combined with epileptiform attacks later there is also confusion death
; ;
results in coma and marasmus.
Chronic Delusions of Jealousy in Alcoholics and Alcoholic Paranoia
Alcoholic delusions of jealousy usually fluctuate with the quantity

of the imbibed liquor and ordinarily disappear quickly with enforced
abstinence in the institution. In very rare cases it appears to survive
the misuse of alcohol and even to become incurable.
Additional delusions and hallucinations, especially of hearing, may
also attach themselves to it so that a complete "alcoholic paranoia" is
present. This, nevertheless, cannot be differentiated from the paranoid
forms in which the specific schizoid symptoms are not very pronounced.
At all events, this outcome requires a special predisposition, and what
is more, it must be one that even previously expressed itself in distrust,
stubbornness, or characteristics evidently of a schizophrenic variety.
By far most of the cases diagnosed elsewhere as alcoholic paranoiacs
I had to consider with certainty as schizophrenics, who also were
alcoholics, and whose hallucinations and delusions had in part an
alcoholic coloring. As a matter of fact they were really sick before
drinking made itself felt. Nor is it conceivable that the alcoholically
conditioned insanity could take root and that especially the alcoholic
delusions of reference could persist independent of excessive indulgence
but the material at present available makes the assumption of an
actual alcoholic paranoia unnecessary. At all events it would be
relatively ifidependent of the quantity of drink consumed.
Dipsomania
There are psychopaths with decidedly differing tendencies who

from time to time become moody. If they endeavor to help themselves
out with alcohol, the symptoms in time become more intense and
frequent, and same time so closely associated with the alcohol
at the
idea that at those times the patients succumb to an absolutely irresisti-
ble impulse to drink. These moods are difficult to describe and are not
at all the same in different patients. A certain world sorrow, a sort
of anxiety, and irritability toward everything that comes along are
rarely lacking, but do not constitute the essential element; an inde-
scribable feeling of dreadful discomfort, a condition "that cannot be
endured," overpowers the patient. Thinking becomes circumscribed,
perhaps also a little unclear; whether merely because of the affect or
independent of it as a concomitant manifestation, I do not know.
To counteract this condition large quantities of alcohol in the most
different forms, preferably concentrated, are consumed, occasionally
also other things, such as ether and even petroleum. But as a matter
of fact the condition improved little or not at all by indulgence
is
in alcohol. Some have the drink brought home to their rooms, most
of them go to the saloon those whose sense of shame is still retained
;
go to one that is distant or secluded, where they do not meet friends;

others go from one saloon to another. Most of them, while drinking,
are shy; a few bluster or quarrel. Real inebriation does not occur.
After about from two to eight days, the attacks pass over; the patients
find themselves, usually after a sleep, anywhere at all, either in a
saloon, or in the gutter, or in the police station. Whatever they carried
with them has usually been converted into alcohol; sometimes they
have only the most necessary clothing left. Recollection is usually
imperfect; the head is confused as after an ordinary severe drink.
They are now ashamed of the past, make the best resolutions but
without success.
In the intervals, that may last several weeks but also many months,
most of these patients are temperate, and some are abstinent. But
there are also chronic alcoholics who at the same time are dipsomaniacs
or who, as it seems> have become dipsomaniacs through alcohol. The
better classamong them can retain their positions or obtain new ones
when necessary.
The disposition for dipsomania we do not understand as yet; it is
probably not uniform. The majority of the patients are psychopaths
who cannot as yet be classified. Others are epileptics or at least in their
entire psychical make-up epileptoid; there are also schizophrenics
among them. Furthermore depressions of brief duration may provoke
similar symptoms in cases that we must number with maniac depressive
insanity. Brain trauma, also, may obviously constitute the foundation
of the moods; in one of these cases we observed that the symptoms

were connected with poriomanic tendencies.
As exciting causes of the individual case, anger, and at times
over-work are mentioned; wliether rightly so, I cannot decide. At all
events the disturbance usually comes entirely from within.

Age. The moods are often noticed soon after puberty; most
first
of the patients come for treatment in early or late manhood.

The differential diagnosis is as a rule easy. The patients ordinarily
describe the compulsion very clearly, and the difference in conduct
in the good and bad periods is uncommonly striking. Nevertheless
very many alcoholics are sent to us as dipsomaniacs, which they are
not; they are people who commit excesses only on certain occasions,
perhaps on pay day, and who can otherwise control themselves, or
they are unrestrained and wavering natures who simply at times go
wild and at times take hold of themselves.
Without treatment the affliction grows worse as time goes along.
But our intervention also is not any too successful. In cases that seem
epileptic bromide is only exceptionally effective, at times, perhaps in
depressions of another kind the results are better. The best results
are obtained when the entire manner of living is regulated as far as
possible and the patient is permitted to undergo a large number of
attacks without alcohol, under the protection of a closed institution.
The depressions then gradually become weaker and less frequent. But
since it takes years to accomplish this, one usually loses patience
before a cure is attained and after the first new excess one has to start
again at the beginning. One, therefore, often tries to keep the patients
outside the institution during the intervals, with the intention of watch-
ing or interning them as soon as the attack is impending. But even
this does not get one very far, because at the given time the patient
all, no will power.
has insufficient insight and, above And the relatives
also no longer summons sufficient energy for immediate action when
the last bad attack has been somewhat forgotten.
Alcoholic Epilepsy
In particularly predisposed persons acute alcoholism excites epilep-

tiform attacks; in cases of chronic alcoholism we frequently see some
typical attacks, especially when any accessory brain disturbance, such
as delirium tremens, Korsakoff, Leukencephalitis supervene. Here the
attacks are probably nothing but symptoms But
of the alcoholism.
occasionally one finds alcoholic epilepsy appearing in their mature
years, which in other respects runs a course about the same as the
ordinary genuine epilepsy and usually develops very slowly into
dementia of an epileptic character.^^
It is probable that the ordinary attacks in alcoholics, which are
especially brought along by delirium tremens, do not come from true
epilepsy, but from other poisons which are of the same nature, as, e.g.,
that of delirium tremens. For the other cases one must presuppose
a particular disposition to epilepsy and often the presence of the two
diseases may be accidental, or the epileptic character may have pro-
duced the disposition to alcoholism. Among those stricken with epi-
lepsy in later years, say after thirty-five, men are in a large majority
and as a rule they are alcoholics; furthermore cases which otherwise
closely resemble the former still seem to be cured in the beginning by
abstinence. One is therefore probably compelled to recognize in
alcoholism the essential casual force of such diseases, that is, to pre-
suppose an alcoholic epilepsy in the actual sense.
The treatment is the same as that for ordinary epilepsy, absti-
nence, eventually also bromides; in those cases which I could observe
for some time, which to be sure were not numerous, the latter remedy
accomplished nothing.
Alcoholic Melancholia
Not very rarely alcoholics suffer from depressive conditions which

cannot be distinguished symptomatologically from a melancholia of
manic depressive insanity, even though the delusions usually remain
merely rudimentary. But they do not last so long, only about two
weeks. Perhaps still briefer attacks are not so rare but they naturally
hardly come to the notice of the physician.^* Some of the suicides of
alcoholics may be attributed to this depression. The attacks may recur
several times in the same patient. The alcoholic character is estab-
lished by the fact that with abstinence, even with temperance, they do
not develop.
B. Morphinism
The chronic use of morphine usually leads to a number of disagree-

able manifestations. Productive ability in all lines is reduced, it
'
If others assert, that the "alcoholic epilepsy" does not present the psychic
signs of genuine epilepsy in its course, they probably have a broader concept
of the disease than is indicated here.
^ Prolonged "drunkard's misery," and severer "moral remorse of the morning
after," cannot be distinctly separated from alcoholic melancholia.
;
becomes especially unequal; with increasing fatigue endurance can be

artificially forced only by incessant doses of the alkaloid. Memory
becomes inexact. Even in organically well disposed characters there
appears an astounding tendency to prevaricate which is not at all
limited to obtaining morphine and to whatever else is connected with
the craving. The morphinist who comes to an institution swears by
everything dear to him that he has no morphine with him. But one
usually finds very considerable quantities of it divided in the clothing,
in the soles of the shoes, in any of the accessible body cavities, or in
any utensil. With every powder or flask that one finds, the protesta-
tions are repeated: that is positively the last one. And they lie to
themselves just as well, because they submit to the treatment to be
cured, but they at once make every arrangement in advance so that
they can be cured only against their own exertions. The character
also changes for the worse in "other respects. The sense of duty is
the patients become
dulled or at least yields to even slight difficulties ;
careless and weak willed in other respects also. The ajfectivity is

fluctuating but rather from within than from without as a reaction to
certain concepts. The mood is very varying on the whole, corre-
sponding to the distance in time from the last injection. Anxiety
feelings may occur also. In severe cases delirious conditions are said
to occur, somewhat similar to delirium tremens. But it is probably
a case of mixed effects from other poisons, especially alcohol or
cocaine.
The physical symptoms consist of tremors, in severe cases also of
slight disturbances of coordination which are general, affecting the
organs of speech, and even the eye muscles. Parasthenias of all sorts
appear, pains or indescribable sensations, buzzing in the ears, and

sensations of heat and cold. The pulse becomes irregular in the
various conditions; beating of the heart is frequent; digestion is
irregular; diarrhoea may alternate with constipation. In severe cases

a definite in the course of years the skin becomes
marasmus develops ;
grayish and sallow. poor

Sleep in spite of frequent tiredness during
is
the day. Libido and potency decline, under certain conditions to zero
menstruation ceases.
All subjective complaints except in verj^ severe cases are banished
at once by a new dose of morphine. Slowly or quickly, according to
the constitution, the body always finds weapons to destroy the poison,
increased doses of which are consequently necessary. With this the
complaints increase and the possibility of obtaining a sufficient amount
of the alkaloid and injecting it becomes less.
in sufficient quantities
The increase of the dose, therefore, has practical limits which most
frequently, perhaps, fluctuate around one gramme a day, and very
rarely exceeds a few grammes, even though daily doses up to twenty
grammes are said to have been observed.
But with the larger doses the patients are severely injured
physically, socially, and especially in their productive ability. They
make attempts to reduce the doses, but few succeed to any considerable
extent. The manifestations of abstinence are too unbearable. They
consist of pains in any place at all, often in the entire body, trembling,
yawning, perspiring, nausea to the extent of vomiting, diarrhoea,
palpitation and poor pulse to a degree endangering life, and then a
feeling of anxiety and unrest which is perhaps the worst feeling of all.
Deliria also are said to result from abstinence. Such a craving for
morphine must be one of the most painful conditions possible. If no
more morphine can be obtained, taking nourishment remains almost
impossible, and there is loss of weight; only after several days does
the recuperation follow.
We do not know positively on what the abstinence symptoms are
based.
Causes. Most morphinists are psychopaths from the beginning.
Even highly gifted and famous men have succumbed to the craving,
and some of them retained their elevated station for a long time in
spite of it. It is strange that one has to call attention to the fact
that they, no more than the alcoholic geniuses, are famous because
they have taken to the poison, but that men of genius are simply
differentfrom ordinary men; on the one hand they are geniuses, on
the other they are inclined to various abnormalities which we may
designate as weaknesses. The accidental causes that lead to the
habit are usually pains which are treated with morphine; but then,
too, there is a certain euphoric reaction brought about immediately
by the first dose, that tempts to repetitions. Naturally the majority
of the patients are medical people; the lower classes contribute only
a small number because morphine is very expensive. In a large
number of cases the doctors are at fault, who give useless injections of
morphine and even place the syringe in the patient's hands. Physicians
addicted to morphine are especially dangerous, because in the alkaloid
craving as in alcoholism there is a desire for similarly disposed asso-
ciates and for proselytizing. For example, we used to have women's
clubs in which indulgence in morphine was the binding tie; whether
they still exist I do not know.
As the morphinist usually either specifies another disease or does
not go to a physician at all, one is rarely in a position to make the
diagnosis from the symptoms. But one must always have morphinism
in mind when one meets people who are very differently disposed, at
times, appearing anxious, run down, weak and trembling, at other
times, especially after they have absented themselves for a few
minutes, being cheerful again. The sallow gray skin often indicates
the disease. One finds the injection scars the more readily because
many patients do not take the time for aseptic measures, even injecting
through the clothing and thus inducing abscesses in large numbers.
The morphine cannot always be detected in the urine. If one wants
to examine former morphinists to ascertain whether they are cured
or relapsed, nothing can be done except to institute a close surveillance.
The prognosis is discouraging; definite cures occur but constitute
a small minority. To be sure, a number of these people maintain
themselves externally in their positions; but few are still completely
efl&cient, they oscillate between suffering and euphoria, and even when
they can work it depends only on the morphine syringe. Many are
ruined physically and socially. Their entire energy is consumed in
obtaining morphine. When there are obstacles in the way of this,
they are overcome with astonishing skill in which lying, theft, and
fraud are not feared.
The treatment demands in the first place the deprivation of the
morphine. The most rational way should be the sudden deprivation;
but cannot bring myself to cause any one such suffering; besides
I
it involves some danger to
life. If one takes a few weeks, in milder
cases only one week, one prolongs the suffering but reduces it very
considerably; this can be done if one takes the pains to control per-
sonally every request for morphine either during the day or during
the night and when necessary, but then only, to administer himself
the effective dose immediately.
If cocaine has been taken at the same time, it can nearly always
be omitted at once with benefit. In the beginning of the treatment
one seeks to ascertain whenever possible the patient's previous daily
dose of morphine in order to reduce it at once to one third or a half.
The patient will usually greatly exaggerate the size of the dose. It
is to be recommended that the patient be informed from the very
beginning that the size of the injected dose will never be told to him.
Then one does not have to he to him, one puts a stop to all grumbling
and above all one avoids the anxious excitations and worriment as
to whether the patient can get along with a certain quantity, questions
which arise as soon as the patient sees that one does not let him
suffer unnecessarily.
It is most earnestly necessary to warn against
sanatoria with which one is not thoroughly acquainted.
If one wants to do anything for the abstinence manifestations, one
should prescribe prolonged warm baths for the restlessness and sleep-
lessness. Local cold applications may under certain circumstances
reduce the heart action; vomiting and hyperacidity of the gastric
juices are combatted with pieces of ice and alkaline water; milk with
ice, later with concentrated nourishment, can sometimes still be fairly
e.g., with tannalbin
well digested; the diarrhoea should also be treated,
injections. Hypnotics should be given only in extreme cases. But
cocaine and similar drugs should never be substituted for the morphine
which would only be adding the devil to Beelzebub.
One cannot expect 'much assistance from the patient. Even the
bravest are dominated by the fear that one will let them suffer too
much and therefore readily demand in every way possible more
morphine than they themselves find necessary at the time. Attempts
to obtain the alkaloid for themselves, especially by bribing the attend-
ants, are very common. A hermetic and absolutely reliable super-
vision is therefore necessary. Outside of a closed institution the
deprivation cure can only be carried on in exceptional cases.
None of the chemical remedies that are supposed to mitigate the
deprivation have proven of value; most of them are simply frauds.
After the dishabituation from morphine there remains the more
important and difficult task, the training of character to overcome
the disagreeable without the aid of a chemical crutch. To be sure it
is rarely possible to remove altogether the firm disagreeable association,
namely, morphine ; it seems as if not only psychic but actually chemico-
organic changes in the nervous system had built up mechanisms that
compel the indulgence in morphine. Relapses are consequently
very common. A certain hold is obtained by the promise, recom-
mended by Kraepelin, to place oneself in confinement for a few days
each year for careful observation. If possible, one should naturally
try to regulate external conditions so that depressive influences are
avoided. When physical diseases threaten, the patient should, if
possible, be put to bed, in order to reduce the temptation to obtain

morphine. It is self-evident that all other poisons, especially alcohol,
are to be avoided.
In incurable cases it has been recommended that the indulgence
be kept at a moderate amount which might be accomplished with
patients who cooperate a little by having them- take treatment each
year in a sanatorium, in which the dose which has grown slowly in
the interval is again reduced. But one must carefully consider
whether one wants to enter on such a compact with which really evil,
is calculated to make the physician, the patient, and those about him
indifferent to a serious and infectious mania.
The prophylactic measures should be self-evident; one should never

use morphine without a very exact indication and especially never
for any length of time, and under no circumstances put the hypodermic
needle in the patient's hands. It is also inadvisable to tell him that
he is when there is no necessity for doing so. Where
getting morphine
there danger one should write on the prescription, "Ne Repetatur."
is
Furthermore no one should prescribe morphine for himself or give

himself morphine even though he has it in his possession. At all events
every physician addicted to morphine, as long as he is not cured,
should be excluded from practicing.
Related to morphinism are opium eating and opium smoking.
Neither is of any importance with us. The manifestations and treat-
ment of opium eating do not differ essentially from those of mor-
phinism. Concerning opium smoking we know little that is certain.
0. Cocainism
Several different types of cocainism can be distinguished which,

however, cannot be sharply distinguished, and also do not exhaust
entirely the manifoldness of the pictures. There is a memory dis-
turbance, similar to Korsakoff, coming after a relatively brief misuse
of from a few weeks to a few years, with excessive irritation, lack of
will power, facile flight of ideas and a preoccupation with various
tasks that leads to nothing. Under certain circumstances disturbances
of coordination similar to those resulting from a state of alcoholic
intoxication are also observed, there is a decline in strength, the skin
becomes sallow and flabby, potency vanishes, and sleep becomes very
disturbed. The picture can show a great similarity to paresis but
one regularly misses the rigidity to light of the pupils. All symptoms,
even the memory disturbance, disappear pretty quickly with abstinence.
In many cases there develops a cocaine insanity, characterized by
extremely small hallucinations of sight and touch, in the form of
mites and other parasites, which the patients sometimes want to
demonstrate to us through a microscope under the impression that they
have made a great discovery. One of our patients saw the cells of
his retina functioning and drew scientific and therapeutic conclusions
therefrom. Voices are rarer in these conditions and some delusions
of persecution are sometimes present. But in other cases the latter
are in the foreground, especially also in the form of uncontrollable
delusions of jealousy {Kraepelin) in which the voices play a more
,
important part. But in both conditions the patients are mentally

clear and orientated; the persecuted patients may become dangerous.
The psychosis usually develops within a few weeks, the hallucina-
tions disappear in from about one to two weeks after the deprivation of
the poison; the delusions may last considerably longer.
As sudden as an explosion cocaine snuffing has spread as an epi-
demic of unsuspected danger; this is especially seen among the demi-
monde and artistic circles but also among university and college men.
It is brought about usually by being led into it by others, more rarely
by the snuff powders for coryza which contain cocaine and can be
obtained without a prescription. This should be forbidden. Since
the dose is usually raised up to several grammes a day, on the
one hand large fortunes may be endangered and on the other hand,
those that gather the large profits are induced to become eager
tempters.
According to Hans W. Maier the manifestations after the first
doses are usually slight dizziness and headache which, however, is
quickly supplanted by a feeling of extraordinary well being. With

this the patients feel mentally stimulated and more productive than
usual, which they really are, but as there is a lack of endurance the
practical results usually amount to very little. A slight flightiness of
ideas may also be noticed. Many then lie for hours in vivid dreams
without, however, losing altogether their critical attitude toward them.
In others illusions and hallucinations, above all those of sight but also
of hearing, quickly appear. Rapidly changing small objects predom-

inate. A splitting of consciousness, similar to that in schizophrenia,
permits the addict of the poison a certain insight into the morbidness
of the perceptions but in the next moment they again believe in the
reality of these morbid manifestations. A strong suggestibility brings
itabout that entire groups may enjoy themselves with hallucinations
that the members have in common. At the height of the poisoning
the phantasies are usually wish fulfilments. During abstinence the
phantasies assume a threatening and fearful character which, with
stomach troubles and creeping skin sensations, lead to new doses.
Only after protracted use does the critical attitude disappear altogether,
the associations become disconnected and develop into the above
described cocaine insanity.
The libido sexualis disappears quickly in the man, while in women,
on the contrary, it is heightened to a desire for all sorts of perversities.
Physically the large, slowly reacting pupils are noticeable; nervous

palpitation annoys the patients; dryness in the throat often compels
them to drink excessively; the appetite disappears and finally there
results marasmus with fatty degeneration of the liver: Heart collapse,
paralysis of respiration, and suicide at times end this sad condition.
. .
The prospects of a cure for cocaine taking are still darker than
those for morphinism because relapses are even more common.
There are no serious abstinence manifestations. Withdrawal of
the cocaine is therefore regularly to be brought about at once. But
usually still other poisons, especially morphine, have been used in
addition, which then necessitates an even longer protracted with-
drawal treatment. But even in plain cases, the after treatment, the
education, requires a long duration with close supervision (for over
half a year)
VII. INFECTIOUS PSYCHOSES

In cases of infection the activity of the brain may be disturbed by
an unlimited number of different influences, such as many kinds of
toxins and antitoxins and a normal metabolic products induced by
these, perhaps also weakness, fever, etc. Our observations cannot at
all follow the manifoldness of the pictures that must result from these
influences. We know only coarse differentiations which, however,

corresponded so little to the differences of the causative factors, that
the monograph on these conditions (Bonhoefjer) had for weighty rea-
sons distinguished only syndromes. The author proceeds on the theory
that we can distinguish different symptomatological steps while the
individual infections can in no way be brought into connection with
the clinical pictures. Thus he distinguishes deliria, epileptiform ex-
citements (appearing and ceasing suddenly), twilight states, halluci-
noses (hallucinatory states without noticeable disturbances of thinking
and orientation), amentia pictures; the latter are at times more halluci-
natory, at times catatonic, and at times of an incoherent character,
then the Korsakoff type, and delirium acutum. For details I must
refer to the original. ^^ The only thing to be emphasized as of prac-
tical importance is that in fever psychoses symptoms may occur which
according to our present methods of investigation cannot be distin-
guished from the catatonic. A catatonic morbid picture may, there-
fore, under certain circumstances be a fever psychosis {Amentia in the
sense of the term employed by Bonhoefjer)
As of theoretic interest it may also be mentioned, that Bonhoefjer
observed a recovery from infectious Korsakoff which came suddenly
after a few weeks.
Kraepelin does not like to surrender entirely the conception of the
connection of cause and effect. The following division follows his
classifications.
^Âschaffenburg. Handbuch der Psvchiatrie. Deuticke, Leipzig u. Wien,

1911, Spezieller Teil III. Abt. 1. Halfte.
A. Fever Deliria
At the height of febrile diseases we see deliria break out, which
unfortunately have been examined very little from a psychiatric point
of view. Four grades are distinguished: 1. The prodromal state with
discomfort, dullness of the head, sensitiveness, anxiety dreams, -etc.
2. Illusionsand hallucinations, especially of sight and also of hear-

ing, in which the patients, either spontaneously or by being spoken
to, become capable for a time of orientating themselves and in a general
way of becoming relatively clear. The hallucinations are often trans-

ferred into the real environment, thus the mother may see her little
children at her bed. The patients become restless and are usually
cheerful or moodily depressed. 3. In the third grade the entire environ-
ment is mistaken. There is complete confusion with lively emotional
outbursts and marked pressure activity. 4. Manifestations of
paralysis gradually appear. The strength to move and express feeling
declines; the patients remain lying on their backs, mumble to them-
selves, pull at the bed clothes, and pick things until they die, often
in a complete coma.
Individual epileptic attacks are rarely seen.
The content of the deliria is as a rule dreamlike. Usually it is a
case of complex deliria which intimately concern the patient's ego.
In pneumonia and perhaps also in other diseases the transition to
anxious conceptions indicates the incipient cardiac insufficiency. In
alcoholics the delirium is alcoholically tinged, animal visions are
especially frequent, etc.
The fever deliria, like most infectious deliria, are usually more
pronounced at night than in the day.
Prospects. Children become delirious relatively easily, so that the
psychic disturbances are not of particularly great significance in them.
Women, also, are said to become delirious sooner than temperate men.
But in adults the completely developed deliria indicates as a rule
the special severity of the infection and with it the danger to life.
However, the first stage is of little significance and many patients

recover even from the third, since, parallel usually with the decline
of the fever, they become clearer and lose the hallucinations. But
sometimes the delusions outlast the disease a long time I know a col- ;
league who long after an attack of typhus requested a friend on the

street to return the money which, since the fever delirium, he believed
he had lent him. The duration of the delirium depends on the disease;
as it is usually a case of acute infections and the psychosis, as a rule,
only appears at the crisis of the disease, it usually ends as early as
the second week either by recovery or death.

The treatment is naturally that of the fundamental disease. Some-

times ice on the head seems to have a quieting effect, as do small doses
of opiates. Due to the fundamental disease hypnotics should be given
with care. many cases cool baths which should naturally be of
In
short duration are effective. To be sure, supervision is necessary; the
patients may come to grief or do harm.
B. Infectious Deliria
Besides the deliria that come and go with the severity of the fever
there are others that seem to be independent of the fever itself since
they appear before or after it, or do not run parallel with the fever in
their jfluctuations.
Mostly in typhus but also in other diseases we observe the initial
deliria which Aschaffenburg has divided into two groups: a paranoid
with delusions of reference and persecution, hallucinations, and de-
pression that is usually anxious or sad and a second form that quickly
;
rises to a complete delirious confusion with flight of ideas, sense decep-

tions and vague delusions, more frequently anxiety, and above all
senseless pressure movements. The two forms are not sharply differen-
tiated ; the first may go over into the second. They usually last only a
few days and may disappear or become ordinary fever deliria. I have
seen a paranoid form in typhus persist far into the period of
convalescence.
The differential diagnosis is not easy; but such initial deliria do
not quite fit into any other symptom picture. In the excited form
one might think of catatonia or epilepsy; the existence of flight of
ideas guards against the second diagnosis the absence of schizophrenic
;
symptoms makes the former improbable.

Like Kraepelin I saw several influenza deliria of a typical neuritic
character, in which parasthenias were interpreted illusionally. At all
events, in grippe psychoses it is mostly a question of a schizophrenic
sort of dissociation of the mental stream, which appears all the more
similar to the schizophrenic because irritations of the nervous system
readily give occasion to a kind of physical hallucination the affectivity ;
invariably, however, continues to fluctuate. Optical illusions some-

times make one think of delirium tremens. States of febrile deliria
readily become mixed, as many patients lose orientation when they
are left to themselves, especially at night. The content of the deliria
and delusions is regularly taken from emotionally toned complexes.
Fever deliria without a schizoid character, often with motor restless-
ness and a tendency to violence, also occur.
In my experience all grippe psychoses which do not look from the
.

very beginning like schizophrenia are curable (that is to say if the
schizophrenia does not just happen to appear at the same time as the
infection)
The typical picture of the Chorea Minor Psychosis ^^ seems to pre-
sent a fairly uniform picture. In the beginning one notes sensitive-
ness, irritability, lability of the affects, and fatigue; vigility and
tenacity of attention decline. The memory becomes poor or at least
the patients appear very distracted. Thinking then becomes very
laborious, and suddenly interrupted; sense deceptions and delusions
supervene, and in severe cases it may go as far as complete confusion
and disorientation. In spite of the severity of the disease, which
permits the choreatic movement to become especially pronounced, most
of these cases, as far as I know, are cured, the delirious state disappears
first, and the chorea a long time after. Cases of chorea gravis show
their character from the very beginning in the sudden rise of the
disease and in the initial prostration of strength. Paralyses soon
ppear and death follows after two or more weeks. In cases not
ûite so severe it may sometimes result in a state of psychic deficiency.
The treatment for all cases of infectious deliria is that of the funda-
mental disease, with careful supervision, avoidance of excitement and
occasions for doing harm to oneself. In chorea gravidarum, which is
not to be taken lightly, abortion is indicated, at least when there is
a physical breakdown, this is often followed by a cure in a few days.

Some, however, recover without any interference.
The delirium acutum belongs to the infectious deliria of a different
origin.^^
A condition appearing with the febrile attack and developing a
violent stateand high grade confusion with dreamlike sense illusions,
flight of change of mood, lively motor excitation, and dis-
ideas,
connected delusions, is called collapse delirium by Kraepelin.
C. Acute Confusion, Amentia

In infectious diseases, puerperal fever, and especially in chronic
nephritis which may not always show itself through examination of
the urine, one finds states of confusion, which ordinarily last for weeks
or months and as yet have no certain positive diagnostic sign. They
are designated with the name of Amentia which formerly included all
^ Naturally only the is referred to here which originates on the
real chorea
basis of a bacterial (Rheumatism). Unfortunately hysterical epi-
infection
demics in schools manifesting themselves in abnormal movements and similar
things are also still called chorea. The medieval Chorea St. Viti, or chorea
magna, was also psychogenetic.
"See p. 163.

possible kinds of confusion, especially also many belonging to schizo-

phrenia. They may disappear, but as a result of the basic disease,
they may also lead to death. The diagnosis can only be made by
exclusion. The conception of confusion or of incoherence are alto-
gether too equivocal to be used in differentiation, especially from
schizophrenia. Where Kraepelin's conception is combined with the
name of dementia praecox, the disease is very rare. Besides infection
and autointoxication, exhaustion was formerly considered as one of
the factors.
Biswanger classifies the "exhaustive psychosis" as follows: 1. Ex-
haustion stupor in mild grades, and acute curable dementia in severe
grades. 2. Exhaustive amentia. 3. Delirium acutum exhaustivum.
These forms, too, cannot be characterized sufficiently. The names

give an idea of the external picture.
D. Infectious States of Weakness

After infectious diseases some patients recover very slowly. For
weeks or months they remain morose, easily exhausted, have difficulties
in thinking, and do not like to exert themselves either mentally or
physically. They are, however, mentally clear and externally ad-
justed (''acute dementia"). In most cases recovery still takes place,
but now and then the condition is serious. Hallucinations, delusions,
and rather severe anxious or depressive moods supervene and the
patients remain permanently demented.
The anatomy of these psychoses is insufficiently known. But
there are cases, e.g. after typhus, smallpox and scarlet fever, with cir-
cumscribed brain lesions, which have also often manifested focal symp-
toms. Sometimes diffuse disturbances are present, especially after
influenza and sepsis, and at times, also, after typhus. It is then a
case of infectious Korsakoff, usually with polyneuritis, which is dis-
tinguished from the alcoholic form by less vividness of the psyche

stuporous confusion is not rare and if life is preserved, is said to
disappear more frequently than in those of alcoholic origin.
VIII. THYREOGENIC PSYCHOSES

Psychoses in Basedow's Disease
Basedow's disease is not rarely accompanied by psychoses which,

however, have no uniform picture. Hysterias often accompany the
basic disease and the frequently present syndromes, similar to neu-
rasthenia, may become so severe that the paralysis of energy takes
on the character of a psychosis. Besides, one also observes depres-
sions with anxiety states and milder forms of mania. Most frequent,
however, one finds pronounced chronic states similar to catatonia
with marked excitements, dissociation of thoughts, confused and some-
times symbolized delusions, hallucinations of hearing and sight, even-
tually of smell and taste, and perhaps even of physical sensations.
Neither in the descriptions nor in the few cases that I have seen myself
can I distinguish them absolutely from catatonic states, as the dif-
ference consists only in the absence of a pronounced schizophrenic
coloring. The affectivity remains livelier, the stream of thought is
not so disconnected, catatonic symptoms are rare or not so pronounced,
etc. All of this may
also occur in patients who have no Basedow
and who after year or more become demented in the typical
a
schizophrenic manner.
The hysterical and neurasthenic syndromes improve usually with
the Basedow. The depressive and manic forms may also disappear
regardless of the Basedow, and rarely accompany the entire disease,
although moods of some sort naturally are hardly ever lacking. The
catatonic variety does seem capable of improvement, but it may not
and readily becomes incurable.
fluctuate at all
The causal treatment depends on the Basedow condition, whereas
the symptomatic treatment is that of the special psychic syndrome.
Myxcedema
(Cachexia Strumipriva)
When the thyroid is completely removed, or severely damaged

anatomically or functionally by a disease, a very definite physical
and psychic symptom complex results. The subcutaneous cell struc-
tures proliferate and degenerate in a specific form. Thus the skin
then becomes generally thick and puffed, but especially in the face
and on the back of the hands and feet; even the nose and tongue
become bigger. This gives the face a plump expression. Pressure of
the finger leaves no fingerprint as is the case in simple oedema. The
skin takes on a muddy pallor, it becomes dry, and scales easily; the
hair on the head, but especially on the body, falls out; the teeth also
become brittle or fall out; the extremities become cold; the body
temperature sinks below normal, and the pulse becomes slow and weak.
Also movements become slow; the same is also true of the facial
mimetic expression which makes the patient look still more stupid.
The finer movements under certain circumstances are also disturbed
in their coordinations, as, for example, writing. The voice becomes
;
grating. Muscular strength is diminished, sensibility is dulled; some-

times actual hardness of hearing occurs. Paresthesias very often
supervene, especially headache, and later a feeling as if the limbs have
gone to sleep.
The essential psychic symptom is the retardation of all processos
of thinking, of decision, and then especially the translation of the
latter into movement; even very simple functions may require many
times the normal time, thus putting the hands on the neck may require
45 seconds. Memory for recent events becomes bad. The patients
notice their deficiency and are consequently depressed in their moods
occasionally real depressions occur but the other affects are clearly
retained. Sometimes one also notices dissatisfaction and distrust
which may rise to the extent of delusions. In severe cases illusions
and hallucinations of hearing, sight, smell and taste also occur, under
certain circumstances even compulsive states. The severest cases
finally develop into hallucinatory confusions; at the same time the
physical strength declines and the patients die, often in convulsion.
Treatment. Continued administration of thyroid extract, best in
the form of ready made tablets, may cause a total disappearance of
the symptoms. It is given first in doses of 0.1 to 0.3 g. of the gland
per day, but the physical strength and the heart have to be watched
very carefully. If necessary, the dose may be increased. If the dis-
ease disappears, the effective minimum dose should be ascertained.
Endemic and Sporadic Cretinism

If the thyroid gland is already absent in childhood or if it func-
tionates insufficiently, a specific kind of idiocy develops. Such chil-
dren remain torpid, psychically as well as physically; they are slow
and awkward in thought and movement. Initiative is reduced, and
in high grade cases it almost entirely lacking. Nevertheless the
is
patients have feelings, and remain good natured, even though at times
they are stubborn. A certain timidity can be demonstrated in most
of them and this accounts for one of the reasons why such children are
slow in learning to walk; but talking also is hindered. As far as our
present knowledge goes the intelligence is not as characteristic as in
the other forms of oligophrenia of which this disease forms a causal
subdivision. Further details will therefore be found in Chapter XIV.
The patients have too few associations, not sufficient over-sight;
during their whole life they give the impression of a non-intelligent
child. Because of their awkwardness and their lack of initiative they
can only perform easier kinds of work. The memory remains good
as far as the patients have a conception of the happenings about them.
They love and fear and hate on the basis of their experience, they
take a lively interest in their environment, and are grateful if one
occupies oneself with them. Thus one can get a very good affective
relationship with them. The sex impulse in the higher grades is weak
or zero. Some cases may show suspicion, delusions and hallucinations,
but such accessory psychoses which usually have a chronic character
are not at all frequent.
^\"
Fig. 18. a Cretin. Age 30 years. Height 112 cm.
On the physical side their small stature is most noticeable. Some

remain than a yard high. The rump and the extremities con-
less
tribute about equally to this anomaly although the extremities some-
times appear especially short. The skull and facial formation is
characteristic. The base of the skull remains short, the root of the
nose is deep and broad; the nose is very short; sometimes the length
is less than the breadth. The ethmoid bone is strikingly broad on
account of which the distance between the two eyes becomes large.
The upper jaw often remains relatively short. During youth the
skin has all the si^ns of myxa'dema " that sometimes disappear in
the third or fourth decade; the skin then becomes wrinkled. But even
Fig. 19. Two Cretins in profile. Height 118 (left) and 120 cm. (right). 50
and 49 years.
earlier marked horizontal wrinkles in the forehead are rarely lacking.

The genitals as well as the secondary sexual signs develop late anatom-
ically and functionally, or remain at a childish stage. INIenstruation
may not appear. In men the beard remains thin or is usually entirely
^Cf. previous chapter.
absent the voice
; is rough and rasping. In manj^ cases there is hardness
of hearing or deafness, in part as a result of middle ear trouble, in part
also as a result of some trouble in the labyrinth. In endemic cretinism
the athyroid signs are on the average less pronounced; dwarfishness
is The hypophysis is in many cases enlarged,
especially less extreme.
but not always. Usually there is a more or less enlarged goitre in ;__
rarer cases the thyroid is reduced; it may even be entirely absent.

The latter is the usual thing in "sporadic cretinism."
According to the degree and relative conditions of individual cases
different forms may be distinguished. Extreme cases are those cretins
which are purely physical, purely psychical,
purely deaf and dumb, and those in which all
three symptom groups are developed to the same
marked extent. The merely deaf and dumb are
usually not classed with the cretins although
according to all we know they belong to it;
however, it is impossible in individual cases
to separate them from other congenital forms
of deafness. According to the grade one speaks
of a full cretin, half cretin, and cretinoid or
cretinous types.
Course. Some of these patients are born
cretins; but in most cases the disease is recog-
nizable only in the course of the first or second
year, reaching its climax in a few years and
then becoming stationary. The patients remain
FiG.20.Extreme-
ly myxoedematous children mentally, and the physical indications
cretin woman, 44 for estimating age are lost to a great extent.
years old. Height
The greatest change is the disappearance of the
99 cm.
Myxoedema in the milder cases. They offer
very little resistance to other diseases and rarely attain old age.
Sometimes brain atrophy with the symptoms of senile dementia appear

very early; I could diagnose them in patients in the forties.
Pathology. There is no doubt that a part of the symptoms of
cretinism, especially the physical symptoms, are the result of the hypo-
functioning or a-functioning of the thyroid. Myxcedema is identical
with the same manifestations in athyroidism. Endemic cretinism
occurs only in goitre regions. Thyroid medication may cause an
improvement in all manifestations. On the other hand, it is striking
that the psychic symptoms do not at all run parallel with the physical
symptoms. There are physical cretins, even of real high grade, who
are psychically still well developed. In goitre regions we meet im-
beciles who exhibit the psycliical character of cretinism but who are
physically regularly developed. Hardness of hearing and deafness,
which in endemic cretinism afflict at least half of the patients, are
absent in other forms of athyroidism, but are common in goitre
regions, among the non-cretinous inhabitants. Hence, between goitre,
psychical cretinism, and hardness of hearing, there is an etiological
connecting link, or besides the goitre an additional cause may be

assumed, or both manifesta-
tionshave a parallel origin in
a commoncause. Wagner von
Jauregg assumes that not only
a quantitive, but a qualitative
disturbance of thyroid function
also plays a part.
The retardation of bony
growth is connected with the
very late ossification of the
diaphysis cartilage (until with-
in the fourth decade) and the
long period of open fontanelles.
The causes of endemic cre-
tinism like those of goitre are
not yet known to us. It prob-
ably has some connection with
the drinking water, of what
kind we do not know.
Other
Fig. 21. Cretin woman in a state of
factors also are probably in- excitation, mosth^ irritation. Hence the
contemptuous challenging facial expres-
volved. A general improve-
sion (veiy rare for a cretin woman).
ment of the social and hygienic She could only grunt but for several de-
conditions without other cades she fooled nearly all new doctors
in the institution with simulated diseases
changes invariably produces a
(scratch wounds among others), need of
decrease of cretinism. In most care and by attracting attention to her
recent times many believe that ovun personality.
there is an infection from one
person to another or a transmission through infected material that

clings to the house or to a dirty bed.
Sporadic cretinism probably has various but not exactly known
causes. In most cases the athyroidism is congenital; but the thyroid
gland may also be injured subsequently, e.g. by infectious diseases. It
may occur everywhere, but it is evidently particularly frequent in

certain places, e.g., in England. In cretinous neighborhoods it can
hardly be diagnosed.
;

The differential diagnosis is very easy in pronounced cases; who-
ever has seen a cretin can always recognize the type. Formerly the
term had a broader and less distinct application, and other forms of
idiocy with physical malformations were also included. The Mon-
golian types that also have a broad nasal base can be mistaken in
youth for light cases of cretinism; but their adipose layer has a dif-
ferent character from that of myxoedema. Later, as contrasted with
the cretins, they become very active. In Nanosomia, or Nanism the
entire body remains small without any great change in the proportions
and as such is not accompanied by idiocy; in Micromelia the retarda-
tion in growth almost only affects the extremities; foetal rachitis
causes entirely different deformities and, like all the above mentioned
forms, lacks the myxcedematous degeneration of the subcutaneous
cellular structure.
In infantile cretins the treatment may still achieve very much.
Thyroid in doses of about 0.5 g. daily or every other day is given, in
larger children naturally a correspondingly larger dose. With this
medication the patients may develop entirely normally; the mental
condition, to be sure, often remains impaired even though it improves
in older cretins an increase of activity but not of intelligence may be
attained. Growth may set in even at the end of the twenties. It
is interesting that in endemic cretinism a thyroid cure often has a
lasting effect while in the sporadic where the gland is entirely missing
the remedy must always be repeated.
Good hygienic treatment is also important in all cases.
IX. SCHIZOPHRENIAS (DEMENTIA PRAECOX)

r After paresis was excluded from among the "functional psychoses"
and the other organic forms followed of themselves, for seventy years
theoretical psychiatry stood entirely helpless before the chaos of the
most frequent mental diseases. Kraepelin, following Kahlhaum's
ideas, was the first to symptomological differences between the
find
acute forms that passed over into "secondary dementia" or "secondary
paranoia" (dementia praecox), and the mild forms (manic-depressive
insanity), and these differences were to the effect that in the severe
forms symptom groups occurred that were lacking in the others but
not the reverse. But a number of diseases taking a chronic course
from the beginning, which were formerly regarded as something en-
tirely different, proved to be identical with the acute psychoses which
terminated unfavorably. Moreover, a large part of the acute syn-
dromes which did not run into dementia, which in the beginning were
exactly like the malignant forms and in the after stages showed, on
exact inspection, more or less pronounced anomalies which only
differed quantitatively from the severe secondary forms, were also
identical with the same psychoses. All these pictures showed more or
less numerous examples of these symptoms, very differently grouped in
the individual cases. But whereas, a manic depressive attack turns
out favorably, one might say always, the prognosis of an attack of
dementia pra3Cox is really not always bad, since in very many cases
after the exhaustion of a shift only slight changes of the psyche call
attention to the disease. But these peculiarities have the identical
character in severe and mild cases, i.e. the course of. the prognosis of
the entire group is the same, while the degree of dementia to be ex-
pected or the extent of the prognosis is not determined by the mere
recognition of the disease. As the disease needs not progress as far
as dementia and does not always appear praecociter, i.e. during
puberty or soon after, I prefer the name schizophrenia.
may come to a standstill at every stage and many of
This disease
its symptoms may clear uq) very much or altogether; but if it pro-
gresses, it leads to a dementia of a definite character.
Even though we cannot as yet formulate a natural division within
the disease, nevertheless schizophrenia does not appear to us as a
disease in the narrower sense but as a disease group, about analogous
with the group of the organic dementias, which are divided into paresis,
senile forms, etc. One should, therefore, really speak of schizophrenias
in the plural. The disease at times runs a chronic course, at times in
shifts ; it may become stationary at any stage or may regress a certain
distance, but probably does not permit of a complete restitutio ad
integrum. It is characterized by a specific kind of alteration of think-
ing and and of the relations with the outer world that occur
feeling,
nowhere Moreover, accessory symptoms, with a specific coloring
else.
in part, are something very common.
A. The Simple Functions

Among the basicsymptoms the disturbances of association ^^ are
especially important. The normal associative connections suffer in
strength; any other kinds take their place. Thus links of association
following one another in sequence may lack all relation to one another
so that thinking becomes disconnected. The following associations
are typical:
"I found the money.// "Doctor, doctor, doctor.// Please give
me some ice water.// "No, I was never here, no, no. The bastard
^See pp. 77-78.
swiped my handkerchief.// Oh, oh, oh. Jack (attendant) you think
you're smart.// "I've eleven of National Baking Powder. Hell, no!
Take that thing away. Lucille, stop crying. Who the devil cares
if he eats. What did you do with Jennie? My word, my word, the
devil you did," etc.^
At the places designated with // in this example the chain of
thought is entirely broken, perhaps at other places also. This makes
the whole thing illogical and incomprehensible. The formal coherence
is also torn asunder. Nothing was said to the patient to stimulate
this production; it seemed as if he reacted to hallucination. This
patient who had a good education used good English when his at-
tention could be held; this entire production corresponds to the dis-
location of the whole stream of thought.
Another example is the following: "Sea water, deep lake, founda-
tion, Interlaken,Davos, Switzerland, I will get there too, I have a high
inland lake, please, please, do we have high tide. Inland water very
cold and quiet. High lake, deep lake, negligeant." ^
The lack of connection frequently finds expression in the answers
to questions: "Why don't you work? (at house-work)." "I do not
know French." Here only the form of an answer to the question is
preserved; the content lacks every connection with the latter.
Sometimes only some of the numerous threads that bind our
thoughts are lacking. This may find expression in the changeableness
and unclearness of the conceptions, even of the commonest the father ;
may speak of himself as the mother of his children. This idea forces
itself, for example, into the place of the proper father idea because he
is just speaking of the loving care of the children, which is more
frequently associated with the mother than with the father; at the
same time the diSierence between himself and the mother (his wife)
no longer exists.
The ideas "land" and "globe" or their connections are treated

in a peculiar way in the following illustration: A patient is given
four small pieces of card board which can very easily be put together
to make the figure of a church. He makes a senseless figure out of it
and calls it a new land a new "globe." ^^
In regard to the progressive stream of thought compare "Brutus

was an Italian" (p. 77), where the relations with ancient times are
supplanted by relations with recent times, or: "Have you any sorrow?"
~ Given by Editor.
" Pfersdorff, die Gnippierung der sprachlichen Assoziationen. Mon. Schr. f.
Psych, u. Neur. Bd. XXXI. 1912. S. 356.

^K. Schneider, Ueber einige Klinisch-psychologische Untersuchungsmethoden
usw. Zeitschr. f. d. ges. Neur. u. Psych. O. 8. 1912. S. 586.
"No." "Are your thoughts heavy?" "Yes, Iron is heavy." "Heavy"

is here suddenly used in a physical sense with a disregard for the
actual connection. Thus the chain of thought and the entire mode of
expression become somewhat bizarre. There is also a separation from
the situation when a seamstress thinks she throws a kiss every time
she wets the thread with her mouth.
The incompleteness of ideas facilitates the formation of condensa-
tions which are consequently unusually frequent in schizophrenia.
Various lovers, various places of residence are no longer kept apart;
sometimes one lover and one place are the representatives of the entire
total conception, at other times others. But in this connection the
expression "total conception" (Sammelbegriff) used in another sense
is
than the ordinary one. No collective ideas originate for the patient
through such condensation; he thinks he has an individual idea and
only the observer is conscious of the fact that in the idea are con-
cealed different separate entities. Further examples of condensations
are "Steam sail" from steam ship and sail boat, and "gruesor" from
gruesome and sorrowful or the sentence: "God is the ship of the
desert" where ideas from the Bible about God, the desert, and camel,
with the figurative expression elsewhere obtained for the useful animal,
are slung together into a senseless sentence.
Often one idea appears for another: displacement of ideas.^^
A patient had left in disgust her position as "support" of the house-
wife; now she gets an uncontrollable antipathy toward everything
that resembles a support or a cane. In these cases the displacement
takes place in the affects but it can also originate in any associative
;
manner: two men are mistaken for each other because they have some
resemblance: the superintendent of the insane asylum is substituted for
the superintendent of the training school. A paranoid female "is a
Billy-goat," i.e., she is united with her beloved minister: Minister =
Christ = lamb = Billy goat.
A form of displacement is the symbol which plays an im-
special
portant part in dementia pra'cox, not in its ordinary application but
in such a way that it takes the place of the original idea without the
patients noticing it: thus the patient sees fire or is burnt, that is, he
hallucinates as realities these things that to the normal person are
symbols of feelings and thoughts of love. He has "heard" that the
superintendent "has stuck his tongue out at him." This is taken
literally (to mean that the tongue was stuck out) although he only ,
hallucinated that he was laughed at.

A catatonic woman hears the stork clapping in her body; that
Comp. p. 118, the hornformed things.
means she is pregnant. A patient is the moon, the wife is the sun.
The wife and the sun represent the thora and justice; the moon is the
sword. The relation of the woman to Dr. B. is Psyche and Amor.
The woman is the goddess of love; she can heal the sick.
Not only may there be an absence of secondary threads of the
mental stream but also of the central idea. There is no visible pur-
pose for writing "Blossom time of Horticulture." ^^ Thus one fre
quently receives letters from patients that describe everything imagi-
nable that is about them or happens to them; they even mention the
trade-mark on their pen but neither the reader nor the patient himself
;
knows why such commonplace things are written down. Besides

letter writing comprehensible and incomprehensible things are ex-
pressed orally and in writing without any purpose, and in the same
way all sorts of unmotivated acts are performed. Through this
change of objective and of the inner association, the train of thought
sometimes resembles the flight of ideas; but the absence of an objec-
tive becomes noticeable through the lack of an emotional value while
in flight of ideas the objective is merely changed.
As a result of the lack of an objective, the train of thought readily
merges into by-associations so that at times mere alliterations be-

come the deciding factors as in "boots beauty." Naturally in this
case some other idea besides the alliteration has influenced the train
of thought but since the same patient, like others also, was accus-
tomed to make similar associations the alliteration cannot be an
accident.
Sometimes apparently senseless associations are explained by con-
necting links that do not come into the patient's consciousness but
nevertheless may be guessed by the observer. Thus when a young
woman answers "sweat shop paradise" to the stimulus word "tree,"
she refers to her unhappy love affair in a sweat shop, where she
"sinned" for the first time tree
of knowledge
paradise, the com-
plexes of her Such mediate associations become evident
disease.
much more in the association experiment than in ordinary thinking.
Through all these disturbances thinking becomes illogical, unclear,
and, when many such mistakes follow one another in a series, thought
becomes dilapidated and incoherent. This dilapidation is still more
increased by a peculiar kind of distractability. In conversation the
patients sometimes appear difficult or impossible to divert because they
enter very little into what one tells them; in spite of all injected ques-
tions they continue their train of thought, but, on the other hand,
they are brought to a topic, totally irrelevant to the subject in hand,
" See p. 78.
THE INDIVIDUAL MENTAL DISEASES 3??
by any accidental things that happen to affect their senses, such as

the ink-well, or a noise. The normal directives through questions
from without and purposive conceptions from within are incapable of
holding the train of thought in the proper channels. If the patients
are governed by an affect, if they begin to scold, distractability is
often entirely lacking.

Conspicuous also is a morbid tendency to generalizations, the
transference of a thought, or of a function generally to other spheres.
Delusions that could only originate concerning a particular indi-
vidual are transferred to others withwhom they have no inner con-
nection at all. The patient has been irritated and strikes the guilty
person but he does the same to others who happen to be near. A
stereotype action is not only provoked by definite circumstances in
which it has a comprehensible significance, but later it is also per-
formed without a recognizable occasion and finally it is repeated
continually for years. An obstruction that originated as the result of
the influence of a definite complex also spreads to other subjects, fre-
quently to the entire psyche and also outlasts the occasion any length
of time.
Thus reasoning is naturally impaired to a great extent. Logical
operations with incomplete or improperly limited concepts and ideas
readily give the wrong results. Deviations from the ordinary train
of thought given by experience also usually lead into wrong directions.
When unrelated ideas are brought together in any connection, wrong
results always follow; this is especially true in the ever>^ day senseless
motivations in which any chance idea is supposed to offer the reason
for a morbid act. The patient breaks windows, "because the physician
is just coming"; he laughs "because the physician is just clearing out
the dresser"; when confronted with the fact that he had already
previously laughed, he says he did it because the things were
still in it. bad actions are motivated by the fact that the
All sorts of
patients are held in an institution and it never does any good to
tell them that the causal connection, if there is any at all, is just the
reverse.
It is especially important, that in this weakness of associations
as in every other, the affects obtain a greater domination over the train
of thought. Wishes and fears control the trend instead of logical
connection; thus the most senseless dehisiotis are formed and the
road is cleared for exaggerated dereistic thinking with its turning
away from reality, its tendency to symbolism, displacements, and
condensations.
Among the formal disturbances of the mental stream the obstruc-
tions (deprivation of thought) are the most striking ^^ and when they
occur too readily or too often or become too general and too persistent,
they are positively pathognomonic of schizophrenia.
The feeling of "thought pressure" should then be mentioned, in
which the patient has the feeling that he has to think, where against
his will "it" thinks within him, and where thoughts are incessantly
"made" for him; all of this is usually accompanied by an unpleasant
feeling of strain.
In many cases there is a tendency to perseveration, the patients do
not get away from one more words and thus,
topic or from one or
aside from a sensible adherence to thesame idea, series like the fol-
lowing may occur: "Love, dove, name, dame, sane, love, dove, names,
dame, same, love, dove, going back, going back, going back, going
back, same. ..." In such cases thinking is usually temporarily or
permanently very impoverished. It is not yet known to what extent
this disturbance of association is connected with the tendency to
stereotyped expressions that show themselves in thinking as in acting.
In moody states one naturally finds flight of ideas or inhibition.
But besides this in acute cases a non-depressive inhibition is not so
rare,which obviously arises from a general aggravation of the central
processes through some chemical or physical anomalies such as cerebral
pressure or inflammation.
In such inhibitions, but even otherwise, we find rather frequently
abnormal brevity of the associations. Such schizophrenics are always
quickly finished with every train of thought without its being thought
out in a normal way. This also accounts for impoverished thinking,

but this is less in the sense of a limitation of the themes than in the
sense of incompleteness of the individual ideas.
Afjectivity. In the severer forms of schizophrenia the "affective
dementia" is the most striking symptom. In the sanatoria there are
patients sitting aroundwho for decades show no affect no matter what
happens to them or to those about them. They are indifferent to
maltreatment; left to themselves they lie in wet and frozen beds, do
not bother about hunger and thirst. They have to be taken care of
in all respects. Toward their own delusions they are often strikingly
indifferent.
In less severe cases we still see affective expressions, sometimes
quite a number them; but they are circumscribed. Especially often
of
we find only irritability which is pathologically exaggerated. The
negativistic patients are therefore impossible to maintain outside of the
institutions because they quickly become enraged about everything
*^Seep. 79.
and yell and fight. The mild and latent schizophrenics on the out-
side are simply considered sensitive and moody people who are hard
to get along with.

Sometimes but not always in otherwise totally indifferent women,
mother love is completely retained, and in more intimate association
with the average patient one still sees many affects, e.g., pleasure in
festivals and games at the institution, laughing at jokes, even joy in
artistic performances. But the finer feelings, based on complicated
processes, are naturally more impaired than the elementary. The
ethical sense does not seem to be especially affected although it
suffers from the general indifference and obtuseness.
In those cases also where we see livelier affects, the entire conduct
generally has the character of indifference, especially in important
matters; their most vital interests, their own future, as well as the
fate of the family leaves the patients entirely cold while cakes brought
at visits are often eaten with relish. In the beginning of the disease
in very mild cases and in late forms the weakening of the affects is
not always visible; on the contrary in individual cases an oversensitive-
ness in various directions may be observed. Then there are active
schizophrenics who with great zeal improve the universe or at least the
health of mankind, etc. But on closer inspection one finds in all these
cases at least partial defects of affectivity, indifference in certain
important matters, temporary reduction of emotivity or contradic-
tions in the interplay of the finer feelings.
Therefore sometimes speak of simple indifference,
one cannot
because there exists a plain fundamental mood of euphoria or depres-
sion or fear. Nevertheless the schizophrenic clogging usually makes
itself under these circumstances also since the mood shows no
felt
modulation; entirely independent of the train of thought the patients

remain in the emotional state determined from within; nothing is
important to them, nothing is sacred to them. The general attitude is
'T don't care," sometimes purely so, at times with a depressive or
especially with a euphoric coloring.
Moreover one of the surest signs of the disease is the incapacity
to modulate the affects, or an affective rigidity. One can speak with
the patients about the most various subjects without noticing a change
of affect,which is especially noticeable in manic moods where one
usually finds very marked emotional fluctuations, while in the less
mobile depressive moods, the schizophrenic peculiarity is not so
conspicuous.
If affects are present, they often do not last. In acute stages
it happens, that without any external reason, patients cr\' and whine


and rejoice and scold in immediate succession. It is a case of a chance
association of ideas which are followed for a short time and are
connected with affective expressions that correspond qualitatively
but are exaggerated quantitatively, just as if an actor were to present
all his emotional roles one after another. Real inability in the sense
that the affects might change very quickly with the mental trend,
directed from within or without, does not belong to the picture of
schizophrenia. A sudden outburst, e.g. of anger, may be frequently
observed but then it is not very easy to divert the affect, even though
one has the feeling that it is "skin deep."

If a change of affect occurs it often takes place more slowly than
in normal people; the affects follow slowly after the ideas or they
appear very capriciously. One does not quite know why they appeared
justnow and why they took this form.
Under no conditions has the affectivity disappeared altogether.
By touching on the complexes one can very often provoke, even in
apparently very indifferent cases, lively and adequate reactions, and in
the dereistic ideas of apparently merely vegetating patients one
finds fulfilments of active wishes and endeavors or even of fears;
the analysis of schizophrenic delusions and logical mistakes shows
that thinking is dominated more by the affects than it is in healthy
people. The entire affectivity may also reappear when an organic
brain disease (senile atrophy, apoplexy) complicates the schizophrenia.
Hence it may be assumed that the morbid process as such does not
attack the affects, but they are functionally only prevented from
appearing, somewhat in the same manner as a child that is suddenly
placed in a strange environment may merge into a stupor without
an affect.^
The affects may also appear changed qualitatively in such a way
that what should produce joy provokes sadness or anger, and the
reverse parathymia. But sometimes only the manifestations are
inadequate; the patients experience joy from a present but complain
at the same time paramimia\^'^
Moreover the affective expressions ar& usually somewhat unnatural,
exaggerated, or theatrical. Consequently the joy of a schizophrenic
does not transport us, and his expressions of pain leave us cold. This
becomes especially plain if one has occasion to observe the reaction
of little children to such expressions. Just as little do the patients
sometimes react to our affects. Thus one speaks of a defect in the
*
Comp. Livingstone, Baelz, p. 127.
" Concerning the schizophrenic unmotivated laughter see among the autom-
atisms.
emotional rapport, which is an important sign of schizophrenia. One

feelsemotionally more in touch with an idiot who does not utter a
word than with a schizophrenic who can still converse well intellectu-
ally but who is inwardly unapproachable.
The affects themselves, like their expressions, have frequently lost
their unity. A patient who had murdered her child, which she loved
as her own but hated as the child of her unloved husband, afterwards
for several weeks was in a condition in which she wept in desperation
^W^^^^^^
:
I
^r vTtikij^HHELîki^^^^^^^^HI ^K.

Fig. 22. Hebephrenic who dictated "Epaminondas" (p. 78), the affected imag-
ination of the facial expression which usually has nothing to express is significant.
with her eyes and laughed with her mouth. Once I even saw such a
splitting of the emotional expression shown on the two sides of the
face. Milder disturbances of the unity of the feelings are more
frequent.
Affective disturbances in the form of acute manic, depressive, or
anxiety moods, are not rare in dementia prsecox. But they belong to
the accessory symptoms.
Parathymias are often indissolubly connected with the alteration
of the impulses.Coprophagia and the most various other aberrations
from the normal nutritive instinct, previously unnoticable sexual
perversions, lack of the impulse of self-preservation are very frequent
manifestations.
Ambivalence. The synchronous laughing and crying are a partial
manifestation of schizophrenic ambivalence. The schizophrenic defect
of the associational paths makes it possible that contrasts that other-
wise are mutually exclusive exist side by side in the psyche. Love
and hatred toward the same person may be equally ardent without
influencing one another (affective ambivalence).^^ The patients want
at the same time to eat and not to eat they do what they do not want
;
to do as well as what they want to do (ambivalence of the will; ambi-
H ^^^BHII^Lii^^l^^l
1
P \
1
Pl^

Fig. 23.
1
/ -
'
'.. .
J u
Rigid, benign mimicry in an erotic catatonic patient.
tendency) ; in the same moment they think, ''I am a human being like
you," and "I am not a human being like you." God and Devil, parting
and meeting are the same to them and fuse into one idea (intellectual
ambivalence). In the delusions too, expansive and depressive ideas
very frequently mingle in multicolored confusion.
The "unimpaired"" functions. Sensation, memory, orientation as
to place and time, and motility are not directly disturbed according
to our present methods of investigation. To be sure one frequently
obtains wrong answers to simple questions, e.g., about orientation, but
this is due to special causes: The patients answer incorrectly because
*See p. 125.
of negativism, or because of sheer mental laziness they talk nonsense,

or they falsify orientation and memory as a result of delusions or the
requirements of complexes.
Perception, as well as orientation, may be indirectly falsified by
hallucinations and illusions. But it is strange that schizophrenics even
in the deeper deliria and twilight states usually show the proper orien-
tation together with the morbid. Although they imagine themselves
in a prison or in hell or in a church, they nevertheless know in some
other connection that they are in the ward of the insane asylum;
although they look on and treat the visiting parents as devils, never-
theless they can later tell that their parents have been there; the
patients know that the wife and child whom he murders are his house-
hold relatives; but he knows "also" that both are devils ("double
orientation").
Thus while orientation as to time and place are not disturbed at
all or only indirectly and temporarily, orientation as to the patient's
own situation is very frequently disturbed, in asylum patients it is as a
rule practically disturbed, deficient, and falsified. Only in exceptional
cases can the patients understand why they have been interned. They
consider themselves improperly treated, take an entirely wrong view
of their relations to their family and to their social standing. That
delusions, especially those of persecution, befog the conception of
their own situation, is self-evident. The autopsychic orientation also
suffers sometimes in which case the personality '^^ is changed.
Memory. The patients usually reproduce their experiences just
as well as normal persons do, frequently even better inasmuch as
they take note indiscriminately of all details, while the normal person
does not take the irrelevant into consciousness at all. Paranoid patients
can often tell the dates of all sorts of trifling happenings. School
learning is retained as well as in the normal who no longer apply it.
.Accomplishments like piano playing, etc., may after an interval of a

decade be practiced as if nothing had intervened.
The registration of experiences is therefore very good. But repro-
duction may be disturbed; much that is related to the complexes may
be blocked or the momentary general condition (lack of clearness
and similar feelings) does not generally permit of a free disposition
of the material. Besides, the patients very frequently appear "for-
getful," as they do not remind themselves at the right time of what
they should do; the housewife forgets to cook, the man forgets to go
to business. But these are not disturbances of memory but the results
of the schizophrenic "distraction."
*See below.
Motility also does not show any disturbances either in respect to
strength or in respect to coordination. We notice in the most delicate
movements, e.g. violin playing, no motor disturbances (the frequent
tremors and catalepsy are here disregarded, some of the latter having
been classed with the disturbances of motility).
B. The Complex Functions

(a) Dereism. Schizophrenics lose contact with reality, the mild
cases inconspicuously in one respect or another, the severer cases lose
it completely. A patient believes the physician wants to marry her.
He tells her the contrary every day, but this is entirely ineffective.
Another sings at a concert in the hospital but much too long. The
audience jeers; but this does not bother her and when at last she has
finished, she takes her seat completely satisfied. The patients make
countless requests of us, orally and in writing, to which they do not
expect any answer at all, although very often immediate necessities,
like their release, are involved. They want to get out; daily they press
the door-knob hundreds of times and when the door is opened it does
not occur to them to go away. They insistently demand a certain
visitor; when he comes, they do not bother with him.
In place of this they live in an imaginary world of all kinds of
wish fulfilments and persecutory ideas. But both worlds are a reality
to them; sometimes they can consciously keep the two kinds separate.
In other cases the dereistic world is the more real to them; the other
is an imaginary world. Real people are "masks," "hastily constructed

people," etc. According to the constellation, in cases of medium sever-
ity, at times the one world, at times the other is in the foreground.
Indeed there are patients, though they are rare, who can translate
themselves at will from one to the other. The milder cases move
more in reality; the severest can no longer be torn out of the dream
world, even though for the simplest purposes like eating and drinking
a certain contact with reality is still retained.
(P) Attention. Naturally active attention is as a result of lack

of interest often permanently very weak. It is all the more striking
that passive attention is usually not only not disturbed but appears
more active than normally. At any interval or external occupation
the patients usually register excellently what goes on about them,
and can make use of the material perceived.
Sometimes, especially in the beginning of the disease, the patients
make every effort to collect their thoughts, but they do not succeed.
This probably involves in part functional disturbances, about like
those in cases of distraction, but besides there are certainly also
general impediments to thinking. In the latter case intensity as well

as extensity of attention arc disturbed, but here, tocj, the passive
invariably less than the active. The tendency of individual cases to
exhaustion also permits the function to weaken readily.
In other respects, corresponding to the character of the disease,
attention is very variable. Tenacity as well as vigility may fluctuate
upwards and downwards. Patients, who for a long time cannot give
attention in any way, are suddenly capable of planning a complicated
plan of escape, etc.
(y) The Will. A good many of the patients suffer from weakness
of will, in the sense of apathy as well as in the sense of lack of per-
sistence of the will. This is frequently accompanied by a fitful stub-
bornness. But under certain conditions definite aims can be held to
with great energy, so that the term hyperbulia is really applicable.
In overcoming pain, e.g. in cases of self-mutilation, the will sometimes
appears abnormally strong.
In addition to thinking, the obstructions naturally also inhibit
willing and execution. But the inner splitting of the will is most
significant. The patients want something and at the same time want
the opposite or when they want to execute an act, a counter impulse
or cross purpose intervenes; subjectively the will often appears
shackled. The patients believe they think and act under the influence
of strange people or powers (being hypnotized; compulsive acts, auto-
matic acts, command automatisms, etc.).
(8) The Personality. Aside from very severe hallucinatory states,

the patientsknow who they are. Sometimes, to be sure, the belief
that they are some one else predominates, and does not permit the
recognition of reality to appear.'^"
__J
(e) Schizophrenic Dementia. Schizophrenic dementia gets stamp its
in the first place from the disturbance of afTectivity: indifference on

the one hand, uncontrolled affects on the other; then from the associ-
ative disturbances, which on account of obscurity and aimlessness and
the interference of by-paths, lead to inadequate, incorrect, senseless,
bizarre, and silly results. But even in severe schizophrenics many
associations still take a proper course and though naturally, other
things being equal, more complicated and finer functions are more
readily disturbed than the simpler and coarser ones, nevertheless the
ordinary failure of a particular function does not depend on its diffi-
culty. A schizophrenic may be unable to add correctly two numbers of
two digits and immediately afterwards extract a cube root. The severer
For the severer disturbances of personality see among the accessory
symptoms.
schizophrenic dementia is distinguished from the milder dementia not
so much by the fact that it also afflicts the simpler functions as by the
fact that numerically there is a decline of functions, be they difficult
or easy. The so-called intelligence test may turn out excellently, but
the patient may nevertheless be utterly incapable of managing him-
self properly in the simplest relations. Under certain conditions he
may understand a philosophical may fail to under-
treatise, but he
stand that he must conduct himself decently he wants to be dis- if
charged from the asylum. Where his complexes are involved he is

impervious to argument, insensible of the most obvious contradictions
of logic, as well as of the conceptions of ordinary reality. The schizo-
phrenic is not downright demented, but he is demented as to certain
times, certain constellations, certain complexes.
The products of pronounced schizophrenia in literature and art
usually have the character of the demented or bizarre, which is not
rarely concealed by a hollow pathos. In -individual cases a slight
degree of deviation from the normal gives the work of art a peculiar
attractiveness, or the patients can utter truths which the normal
person does not dare exhibit in their nakedness. Not rarely schizo-
phrenic excitement produces at first a certain impulse to poetic activity,
and even a certain ability otherwise lacking.
(t,) Activity. Schizophrenic activity may be readily deduced from
the disturbance of the affects and the associations. Where the affects
are prostrate, little or nothing is done, where in the very severe
cases dereism dominates the patient, he no longer bothers with the
outer world. Lack of initiative, the absence of a definite aim, the
ignoring of many factors of reality, dilapidation, sudden notions and
peculiarities, characterize the middling severe cases. The milder
cases live like other people, only now and then the abnormality is
noticed. In all cases we find an insufficient motivation of individual

acts and of the entire attitude toward life. The patients change
their position and calling, or without reason fail to appear at their
work, are moody, and inclined to pout and scold. In the
irritable,
organization of the asylumsmany can be very good working machines,
but even on the outside, many whose view has been narrowed by the
disease are still considered ideal workers, until a stupid act reveals
their condition. A teacher suddenly lies down in a well, a young
woman sews stockings to the carpet, etc.
Where accessory symptoms as, for example, hallucinations, delu-
sions,manic or catatonic syndromes are present, these primarily de-
termine action and conduct.
The excited cases in asylums are very unpleasant: Yelling, scolding,
fighting, destroying, all sorts of uncleanliness, are every day occur-

rences with many; special peculiarities, coprophagia, scraping the walls
and beds, refusal of food, impulse to suicide, self-infliction of injuries,
make the treatment of individual cases especially difficult; but v/ith
the improvement of the technic of treatment, and with increased
understanding of the patients these matters are becoming more rare
and of shorter duration.
C. The Accessory Symptoms

The accessory symptoms complicate the fundamental picture, at
times permanently, at times only in transient appearances.
(a) Sense Deceptions. Characteristic of schizophrenia are the
hallucinations of bodily sensations in clear mental states; besides there
pronounced preference for auditory deceptions in the form of
exist a
words (voices). Visual hallucinations are very frequent and lively
in the acute stages, otherwise rare. Tactile hallucinations occur almost
only in combination with bodily hallucinations and as partial mani-
festations of a complicated perception (snakes, being struck). Decep-
tions of smell and taste and of the kincesthetic senses occasionally
obtrude themselves.
The patients hear blowing, roaring, humming, rattling, shooting,
thundering, music, crying and laughing, but above all whispering,
speaking, calling; they see individual things, landscapes, animals,
people and all sorts of impossible figures; they smell and taste all sorts
of pleasant and unpleasant things; they touch things, animals, and
people and are struck by rain drops, fire, and bullets; they feel all
the tortures and perhaps all the pleasant things also that our bodily
sensations can transmit.
Elementary hallucinations of hearing are rare and influence the
patient little. The voices usually speak in abrupt words and short
sentences; long, connected scenes are signs of accompanying alcoholism
or, in rare cases, of twilight states, and hysteroid additions. They
scold, threaten, console, they criticize as ''voices of conscience," or
also say the opposite of what the patient wills or thinks. In the case
of the thoughts becoming loud, on the contrary, what is thought at
the moment by the patient is spoken out. The voices come from all
sorts of places, from heaven and hell, or from ordinary places, where
people are; but they are also situated in the walls, in the air, in the
clothes, or in the body Perhaps they use only
of the patient himself.
one ear, or the good voices are heard in the right ear and the bad
ones in the left.
The hallucinations of bodily sensations offer an endless variety.

The patients are clubbed, burnt, stuck with hot needles, their legs are
made smaller, their eyes are pulled out, the lungs are sucked out, the
liver is taken out and put into another place, the body is pulled
apart and pressed together like a harmonica, a bullet runs along
the top of the skull from the base to the top, the brain is sawed apart,
the heart beat is decreased or increased, the urine is drawn out or
held back. But above all the joys of normal and abnormal sexual
satisfaction and, more frequently, all sexual indecencies that
still
can be imagined are the semen is drawn off, the outer and inner
felt;
genitals are burnt, cut, torn out, women are violated in the most
refined manner, are forced to intercourse with animals. The sexual
element in the sensations is often disguised; a female patient feels,
instead of the sexual act, that a hobby horse is in the bed.
Sexual experiences are transferred to the heart, to the mouth, to the
nose, etc.
Hallucinations of sight are rare in chronic conditions and when
present are usually fragmentary and disconnected; a head, angels
as large as wasps, and hands appear before the patient, sometimes also
a sexually symbolic animal, a snake, an elephant, a horse. In acute
delirious conditions an entire background is hallucinated; paradise,
hell, a castle, a dungeon, all with acting inmates. At the same time,
reality may be hallucinated out of the way, or illusioned to correspond
with the hallucinated milieu; in more clear cases some of the pictures
are injected into reality, and in an altogether clear consciousness
all are so injected.
Where it is possible to hallucinate, illusions also appear; but they
are less important than the hallucinations. Sometimes the two forms
of sense deception cannot be distinctly separated.
The deceptions of the different senses, especially in acute syn-
dromes, combine very readily with one another. The patients experi-
ence scenes, see persons act, hear them speak, feel their influence, smell
or taste their poisonous or pleasant presents. In mentally clear chronic

stages, usually only voices and somatic hallucinations combine. The
sense deceptions appear most frequently when the patients are left
to themselves. But there are exceptions; now and then they appear
especially disturbed during work. They are often provoked by
another sense impression: the patient sees the physician come into
the ward and at once hears him utter a command that concerns him-
self; the key turned in the lock is felt painfully in the breast {reflex
hallucinations). Not so rarely the hallucinations are dependent to
a certain extent on the will; the patients ask questions out loud or in
thought; they are answered for them; they put themselves into certain
situations where the sense deceptions appear, or into others, where

they are free from them.
The intensity of the hallucinations may assume all degrees, from
the least whisper to the terrifying thunder tone, from the slightest
abnormal feeling to the most unbearable pain.
In the same way the clearness fluctuates within maximum limits.
Frequently the false perceptions are really very obscure. But the
patients do not notice it because the meaning of these perceptions is
plain to them in advance; they hallucinate the meaning much more
than the word. When they are pressed to reproduce a voice word by
word, they often do so using different words in immediately successive
times; but the sense, e.g. of the denunciation, remains the same; a
distinct smell comes from snake-poison or from morphine, etc.
The same is true of the projection to the outer world, which is quite
indefinite for the patient, much oftener than he at first notices. On
closer inquiry it often turns out that the patients do not differentiate
between vivid thoughts and real voices, between ideas and prepared
pictures and (hallucinated) objects, and do not feel the necessity of
doing so. Extracampine hallucinations occur most frequently, espe-
cially in schizophrenia.
In spite of the value of reality of the hallucinations for the
this,
patients usually holds as self-evident. They usually believe in the

voices with unshakable conviction, and when these come in conflict
with actuality, it is the latter whose reality they reject, or at least
doubt. Hallucinations, the morbidness of which is recognized in spite
of the vividness of the deceptive perception (pseudo-hallucinations),
occur most readily in the visual sense.
Thus the patients cannot readily evade their hallucinations, while
in ordinary life one can ignore a large part of the normal sense
impressions. Only after a long while some of the more intelligent
learn to pay no attention to the sense deceptions. Most of the patients,
who in spite of all hallucinatory annoyances gradually become quieter,
in time adjust themselves to them in such a way, that they transfer
themselves into another world, into a separated part of the ego, which
is decidedly cut off from reality. Thus they can work quietly or
otherwise adapt themselves to the asylum routine although they hear
voices incessantly and are tortured physically.
Contrasted somewhat with this persistence of the schizophrenic
hallucinations there the peculiarity that, as soon as another train
is
of thought is present, they are readily shut off or split off. Even
patients who are almost incessantly occupied with their hallucinations
and are influenced by them, consequently cannot even with the best
intentions give any account of them when they are questioned about
them.
The patients have the most various conceptions of the manner in
which the hallucinations originate. Often they are tortured with
complicated machines or telepathic influences. Formerly it was
witchcraft. Special talents also, "second hearing," enable the patients
to hear voices. Not rarely the need of an explanation is entirely
lacking.
The attitude of schizophrenics toward their hallucinations is most
varied. Many adjust themselves to them, others even quietly amuse
themselves with them ; but very many react with excitements, threats,
and violence. In acute twilight schizophrenics sometimes
states,
occupy themselves in accordance with their imaginings or they submit
passively to everything; they lie around catatonically, partly with a
consciousness of the absence of reaction, partly as a result of kin-
aesthetic hallucinations with the belief that they are doing something,
like the normal person in a dream.
(P) Delusions. The schizophrenic delusions show in most cases

the impress of the illogical. In the delusions themselves contradictory
and absolutely unrelated ideas can exist together; the most decided
contradiction of reality is not felt. The physician is at thesame time
their friend Jones, but besides "he may come as Thomas or Smith."
The patient himself is long since dead but he lives in the asylum.
A catatonic woman
swallowed the whole world with every gulp; a
patient has had his head cut off many times. Often the ideas are
extremely indefinite. He has one hundred thousand dollars, which
occasionally, without noticing the contradiction, he estimates as ten
dollars. Many ideas are intended entirely symbolically; a female
patient "is" the cranes of Ibycus because she is "free from blame and
error," and "free," that is, she should not be confined.
The individual delusions have little or no logical connection among
themselves; they often constitute a real "chaos of delusion." But
usually they readily become organized in accordance with affective
needs. The patients want to be more than they are and this then
results in the delusion of grandeur. They do not get what they wish for,
and as they themselves do not want to admit that they are incompetent,
the result is the delusion of persecution.
In respect to content the most prominent part is played by perse-
cutions. Particular individuals, relatives, superiors, the physicians
in the asylum, but especially complete plots, the free masons, the
Jesuits, the "Black Jews," mind readers, "Spiritualists," persecute
the patient with voices, slander and annihilate him, subject him to
.
all the tortures which objectively we ascribe to the bodily hallucina-

tions (physical delusions of persecution).
The delusion of grandeur permits the patient to be a genius or
some other great person, such as an inventor, count, Kaiser, pope,
Christ, or prophet. This delusion is rarely altogether pure but is
usually mixed with that of persecution. Erotic aspirations are nearly

always present in women, and very frequently in men. If they are in
the foreground there is usually at the same time involved, at least in
women, an exaltation of rank; they have a lover who is socially

above them; envious people are at fault that he has not as yet married
them. The delusion of jealousy also may be schizophrenic. The
delusions of poverty and sin usually exist only in depression. However,
delusions of self-accusation may also be the expression of suppressed
wishes or merely the result of chance associative connections. Thus
a patient falsely accused himself of having violated a girl. In a
village, where there had been several fires, a schizophrenic got the
idea that he had caused them. People who in case of a sensational
crime falsely surrender to the police as the criminals are usually
alcoholic schizophrenics.
Autopsychic delusions are very frequent; the patient is not at
all the person for whom he has been taken, but an entirely different
person; his name is not the one shown in the documents, he was
frozen in a bathtub and is here anyway; a young woman "is inter-
changeable, at times a virgin, at times a woman." Other patients are
changed into animals, a delusion which to be sure rarely persists in
clear states. Sometimes the ego also is changed. Then again it is
not the patients at all who think and act, but strange powers in them
(Demonism)
All schizophrenicforms of delusions, above all the delusion of
persecution, draw their sustenance in large part from an uncontrollable
delusion of reference. Everything that happens can have some ref-
erence to the patient, not only what people do, but external events also:
a thunder storm, a war, etc.
Usually the delusions are self-evident truths to the patient. Some
patients, to be sure, themselves feel in a certain connection the absurd-
ity or the peculiarity without, however, being led to make a correction.
The reaction to the delusion is sometimes adequate, in the sense that
the persecuted ones complain and defend themselves, or the megalo-
maniacs want to carry out their presumptions; one wears a high hat
to show his dignity as "inspector of the asylum" another strikes any;
person at all whom he considers a persecutor; or to ward off the

secretive "influences," counter measures of a magical character are
resorted to. But much more frequently the conduct of the patients is
inadequate. They really do nothing to attain their goal; the emperor
and the pope help to manure the fields the queen of heaven irons the
;
patients' shirts or besmears herself and the table with saliva.

Delusions formed in acute states may
be carried over into the
quieter states as "residual delusions" But usually they
(Neisser).
disappear with the other acute manifestations even though a schizo-
phrenic hardly ever attains an entirely objective attitude toward a
delusion. A delusion formed in chronic states is usually retained a
long time, often for life, even though it is rare that it does not in
time experience additions and transformations which, however, only in
exceptional cases change it materially. At all events in the stages
of higher dementia, where the withdrawal from reality clouds the
judgment most seriously, we find the wishes most frequently gratified
by the delusion of grandeur, while previously the impediments to
wish fulfilment came more into consciousness and occasioned ideas
of persecution. One of the commonest and often very rapid trans-
formations is the one where the beloved becomes the persecutor. With
a change in the surroundings delusions that are attached to them are
sometimes forced into the background for a short time; but soon the
new environment seems the same as the old and attracts the previous
delusions to itself.
The delusions, in large part, turn up in the form of hallucinations,

others as visual deceptions; many suddenly spring from the uncon-
scious as primordial ideas; many originate in a dream in which case
it is significant that the patients often know the genesis without on
this account entertaining any doubts as to the correctness. To be

sure, manic and melancholic shifts of mood form corresponding ideas.
(y) The Accessory Memory Disturbances. Occasionally hyper-

mnesias appear, in which individual recollections turn up with special
vividness, sometimes with the character of compulsion. Memory
gaps or amnesias occur, more frequently, e.g. after deliria, but also
after merely psychically conditioned excitements. But paramnesias
are most common, in the form of illusions as well as in the form of
hallucinations of memory. A patient who inwardly is not entirely
satisfied with her husband accuses herself of having slandered him
dreadfully. Many find in print what they have thought some time
ago. What others have written, they have written about long ago.
It is very common that patients who do not get along with those
about them believe afterwards that they have endured many hard-
ships on their account, while in reality they were the aggressors, or
nothing special has happened at all. Memory hallucinations are very
common. Suddenly, while playing cards, a patient becomes excited

and complains that yesterday at a particular time, which he really
spent very quietly, his clothes were taken off him and he was beaten."
Memory deceptions through identification are much rarer. '^ But
when they are once present, they may be consistently retained many
years, so that e.g. a patient imagines every time something happens
that it occurred exactly in the same way on the same date of the
previous year.'^^
(8) The Personality. Loss of a feeling of activity and the inability

to control the thoughts often rob the schizophrenic ego of essential
components (depersonalization) Disturbance of associations and
.
morbid bodily sensations make it appear entirely different from what

it formerly was, so that their changed condition is made conscious
to the patients; they have become a different person, or they must

at least "find their own self for short periods." The restriction of
the ego when contrasted with other persons, even things, and abstract
conceptions, may be obliterated; the patient can identify himself not
only with many other persons, but with a chair, or a staff. His
recollections are split into more parts; the one set of his
two or
experiences he ascribes to the real John Smith, the other to his new
personality which was born in Charenton and is named Midhat Pasha.
Others become a new personality at a definite moment.'^*

Objectively the personality suffers from the marked independence
of the individual complexes. On ordinary occasions a patient may
appear normal. If he is brought around to his delusions, he is altogether
different, with a different character, with a different logic, with a
different expression. On the other hand many severe catatonics may
be completely opened up, by a discussion of their complexes and
change their conduct, so that temporarily the disease can hardly be
demonstrated. Towards some persons many schizophrenics are out-
wardly normal, toward others they are brutal, or shut-in, or negativ-
istic. But in this case it is not as if the change were willed or even
conscious. There simply exists an entirely different shift; feelings
and impulses, and even associations, which dominate in one picture
are inhibited in the other, and in their place others substituted. Both
dissociation products of the personality can exist side by side. I
observed this most clearly in a patient who, as a rule, while she listened
to a reading and comprehended it faultlessly, or even while con-
" Compare further p. 105.

" See p. 108.
"For negative memory hallucinations see p. 101.
"Comp. p. 391, the autopsychic delusions.
IV^
versing with us, entertained herself with her pathological creations
by whispering quietly or making gestures.''^
nowhere so frequent as in schizo-
Transitivistic manifestations are
phrenia. Very commonly, the patients are convinced that those about
them also hear their voices, sometimes even that they undergo the
physical persecutions with them. A patient has holes in her hands
and maintains that the nurse also has holes in her hands. A patient
strikes himself twenty times in the belief that he is striking his
enemies. A hebephrenic patient believes when he does anything, e.g.
scratches his face, that he does not do it at all, but some other person
whom he sees in front of him.
A woman who nursed her husband,
Appersonifications are rarer.
who was from intestinal cancer, believed that she had the
suffering
same disease, whereby her disease first became manifest. The bed
neighbor of a woman patient died; she, thereupon, considered herself
as having died.
In twilight states, or in attacks of rage the patients are often
entirely different people as to character and ideas. Change of per-
sonality of the most different kinds are often indicated, not only by
attitude and conduct, but occasionally also by different speech; one
personality speaks in a low tone, the other in a loud tone; one articu-
lates childishly, the other normally.
(e) Speech and Hand-writing. Most schizophrenics do not show
anything striking in their speech, but among our asylum patients
disturbances of this function are not rare. Frequently the speech
impulse is changed: the patients speak a great deal, often without
saying anything and without a comprehensible reason; others no

longer speak at all (Mutism), and for different reasons. At times
they offer the information that ideas of sin forbid them to speak.
But that the delusions should have just this content requires a
cause lying further back, e.g. negativistic tendencies; speech may
also be temporarily hindered by obstructions. The most important
reason for protracted mutism is undoubtedly, that the patients haye
lost contact with the outer world and have nothing to say to it.
If the patients speak, the tone may be abnormal, too loud, too
low, too fast, too slow, falsetto, humming, grunting, staccato, rushing,
etc. happens that patients do not open the mouth to speak,
It also
as a result of which understanding is naturally reduced to zero. Then
again speech may be without any affect, monotonous, or embellished
in some way.'^^ Speech mannerisms often express a definite complex,
"Compare also the double orientation, p. 111.

" For verbigeration see under stereotypism.
the child complex in diminutives and high voice, social aspirations

in the use of foreign words and intonations, that are supposed to be
superior. A catatonic woman, even in her clear states, usually spoke
J4t-îfJ--' XitÂT ^JZJcJ, .A.^w^-^^^.^'^-r^^ Ji'-kji .^^ '^^^^^ (^k/)^^
^T^/c^TT. .-STTlvC' /TVl'Âii-C-M '"tA^ Û. .-r^-lLj i^-A-u-'l^C JC i"r.Tl, >^
;2l .^ -^^^^'^^ ''"'"^ (^^^ cx_ ^
Fig. 24.
Writing of a hebephrenic. The script changes from small to big
hand, words are frequently underlined and some changed and scratched out.
an ordinary Zurich German, but concerning her disease always in

the St. Gall dialect; when her husband was discussed, she used
vulgar expressions and curses; on the subject of "America." which
)r&n 1.
'ii'
2.
<h^1-
V,v,
c^ c^^.^..^ ^=4}
V.
1. i_iJ-^- S->vuiM. VocTCa*. vôr\ik<^
2.
2~^ i,,
^ 2-
OTKnC^X

^
Fig. 25. Letter written by a schizophrenic patient.
2- 2-
Incomprehensible, con-
-2-,
taining stereotype expressions, neologisms, of words and numbers, and peculiar

figures.
396
was connected with her aspirations, she used educated, decent

expressions.
Frequently ideas are designated by other words, "courageous"
by "rowdy," a wall clock by "buffet," or neologisms are formed, in part
CV^-e>-'Jo-r>)
Qo^ ^î<_*C^Q_ ^^;>O^CrvÂ<^
VA>Jl^C>^^
Fig. 26. Flourishing writing of a paranoid praecox patient who shows grandiose
feelings of the aristocratic type.
for existing ideas, in part for the designation of new conceptions.

"Double polytechnic" means the inclusive idea of all the patients'
aptitudes and the rewards belonging to them; one gives the patient
pain "on the cosmos path," At times grammar fails them {paragram-
matism). Many words are used incorrectly, thus e.g. frequently the
word "murder" that designates all the tortures that the patients suffer.
"I am England" means: "England belongs to me."
At times only words are used or written, which have no meaning
for us (Word Salad) or the patient speaks a particular "artificial
language," sometimes with the pretense that it should be understood.
The written expressions correspond to the oral. Abnormalities of
style of all sorts are frequent. The handwriting is sometimes over
decorated or entirely affected; it not rarely changes very much sud-
denly, as if it came from another person; it contains repetitions of
letters, of words, of all sorts of signs (written verbigeration) , omissions,
or excessive use of punctuation, and peculiar orthography. The ar-
rangement of the writing, and the folding of the paper are often
striking. In catatonic "unclearness" accidental mistakes occur,
especially the omission of letters, the contraction of two words into
one (In't instead of I not), contamination by later words that the
writer already has in mind.
(^) Physical symptoms are usually not pronounced; but some-
times one comes across signs of cerebral pressure which is to be ascribed
in part to an oedema in the skull, and in part to a special "brain
inflammation."
The weight of the body shows large and unaccountable fluctuations;
a marked addition of fat is especially frequent during reconvalescence
from acute attacks. During catatonic states we frequently have a
severe disturbance of metabolism; the picture looks like an infection:
thickly coated tongue, tremors, rapid decrease of weight and strength
even when sufficient nourishment is given, and sometimes also slightly
increased temperatures. The metabolic disturbances, as well as the
cerebral inflammation, may become fatal.
The functioning of the intestines and the different glands in most
chronic cases is, as far as we know, normal, but under certain condi-
tions very irregular; constipation may alternate with frequent move-
ments, polyuria with penuria. High grade ptyalism and parched
mouth occur in the same way.
The functions of the vaso-motor system are perhaps most strikingly
changed. Without comprehensible reason the pulse may fluctuate;
livor and cyanosis often occur, which in rare high grade cases may
go as far as blue-black coloration of the hands and feet. Then again
the head or any other circumscribed part of the body is overheated,
another part is cold. (Edemas of a striking consistency appear on the
feet, in the face, on the wrists, occasionally also on very unusual
places. Menstruation is often disturbed, but more in the sense of
^r^ y^
^1 1'!^ i ^^
0?
# *i
-Q
35
2 S
reduction than in hyperfunctioning. Especially in acute stages it
usually ceases for a time. But the subjective menstrual troubles

common in mentally healthy women hardly occur here, an important
sign that they are psychically conditioned. Men are sometimes
impotent or there is at least a reduced libido.
Naturally during acute shifts sleep is usually disturbed; in con-
trast with this one sees at times a protracted desire for sleep. Chronic
patients sleep normally at times, at other times they are kept excited
through the night by hallucinations.
The manifestations of exhaustion vary greatly; especially in the
beginning they form at times a prominent symptom. At every task,
3specially thinking, the patients immediately become tired and conse-
[uently fall back on as complete an inactivity as possible, sometimes
ifter a hard struggle against the evil. On the other hand others
hardly feel any tiredness, either at work or at the exertions caused
by the excitations or the hyperkineses.
Of the motor symptoms there are still to be mentioned the frequent
aggravation of the idio-muscular contractions and fibrillar or muscular
twitching in the face, then fine tremors. Coarse tremors occur only
in acute disturbances with weakness.
The gait in severe cases is often striking as aimless, and irregular
in respect to length and duration of the step. Organic paralyses do
not belong to the picture of schizophrenia, but hysterical forms of
all kinds do, even though they are not particularly frequent.
The deep reflexes are usually exaggerated. In acute conditions the
pupils are often pathologically dilated, rarely and probably only in
chronic patients excessively contracted; more frequently, but tran-
siently and variably, the pupils are unequal. Usually the psychic
pupillary reflexes are absent.'^^
Besides the hallucinations of bodily sensations parasthesias of all
kinds are very frequent and often constitute for a long time the only
symptoms of the disease. Worthy of note is an analgesia which occurs
not too rarely and which is sometimes quite complete. It is responsible
for the fact that the patients readily injure themselves purposely or
accidentally.
Sometimes catatonic attacks occur which show two extreme types
with every possible intermediate forms. On the one side one observes
attacks that appear purely psychical, evincing a hysterical form; on
the other side there are organic attacks with disturbances of con-
sciousness, interference with the thought processes, involuntary
evacuations, and occasional residual mild paralyses of speech, facial
" For catalepsy see below among the catatonic symptoms, p. 403.

Fig. 28. Letter written by schizophrenic patient who is controlled by senseless
ideas of grandeur. The patient has invented a new language which one can,
however, occasionally decipher. Thus for INIanhattan State Hospital he writes,
"Nehat hsiat." One can also recognize in the 2nd line, the words "New York,"
'
the 2nd of April; and in the 3rd line "Dr. Heyiuan" (the superintendent of the
hospital). Occasionally one can also find correct words. The patient is a native
American.
Fig. 29. From the note book of a chronic catatonic. Verbigerations in

letters,
childish drawings in spite of the fact that the patient can really draw quite well.
nerve, or hemiplegia. If the patients are not entirely unconscious

with they are delirious in the sense of a more or less perceptible
this,
hysterical twilight state. Besides there are fainting spells, and espe-
cially typical epileptiform convulsions also.
Physical deformities (stigmata) are obviously somewhat more
frequent than in the normal persons but much less frequent than in
idiots, epileptics and criminals.
(ri) With this name a number of symp-
The Catatonic Symptoms.
toms were designated which at the time helped to formulate a definite
conception of catatonia. They
may readily occur singly, but it
is not improbable that they nev-

ertheless have an inner connec-
tion in the sense that they occur
most frequently with a certain
condition of the brain that is at
the foundation of catatonia.
L Catalepsy (waxlike flexi-
bility, pseudoflexibility, and

rigid catalepsy).'^
Most of the severer catalep-
tic schizophrenics assume defi-
nite attitudes for months and
years one stands at the window
;
on the tips of the toes of one

foot,holding up the other leg
and both hands. Others as-
sume a particular attitude in
bed, etc. Usually these forms
are associated with rigid cata-
Fig. 30. Spontaneous attitude of a
lepsy. catatonic, at fii-st lasting, then only as-
2. Stupor. Stupor of vary- sumed when the phj-sician appeared.
ing origin is very frequent in
acute conditions but may also characterize a chronic stage for decades.
The patients move
speak little or not at all, and generally limit
little,
intercourse with the outer world as much as possible. Cataleptics are

naturally all stuporous. Many appear depressed ("^lelancholica
attonita"). In severe cases there are usually verj' numerous hallucina-
tions of all senses with a falsification of the outer world and the
environment; the patients are in a dream land.
3. Hyperkinesis. Many catatonics are in incessant motion: they
''See p. 153.
nod the head, hop, hammer on the bed, throw themselves about, dash
themselves on the head, let themselves fall backwards over the foot
end of the bed, climb up wherever they can, all in a peculiar manner
that seems purposeless.
4. Stereotype Expressions. The inclination to stereotype expres-
sions is prevalent in all fields. It may just as likely be transient as
it may for decades provoke the identical movements and the identical
attitude.
Stereotype Move-
ments: Rubbing the right
hand over the left thumb
for decades; continuous
rubbing with the right
hand over the middle of
the breast; running the
finger along all edges;
tapping with the foot on
certain places; knocking
on a particular part of
the bed; turning about
the vertical axis with a
particular position of the
arms, etc. Some stereo-
types have the character
of senseless acts: pulling
out the hairs at certain
places, sticking the finger
into the anus, smearing
in a particular way, twist-
ing the clothes, ripping
Fig. 31. Permanent attitude of a catatonic,

off the buttons.
who in spite of all measures finally suffered Stereotyped Attitudes:
from a pretty severe kyphosis. many catatonics who lie
bed hold the head

in
away from the pillow in a position which the normal person could
not endure very long, or they draw the knee up to the chin, or
stand rigid like an Egyptian statue; they hold the legs spread apart,
stare for weeks at the same spot, under certain conditions with an
extreme awry position of the ejês.
Stereotypes of Place. The patients want to remain only in one
particular place, always walk exactly the same paths in the garden, so
that these become trodden down, or they touch the wall at certain
places, thus leaving marks of this constant wear and tear.
.
THE INDIVIDUAT. MENTAL DISEASES 405
A particular stereo-
type is the "snout
cramp" which the
in lips
are held protruded for-
ward.
The stereotype of
speech, or verbigeration,
always repeats the same
words or sentences,
often entirely senseless
ones. This is not to be
confused with such in-
cessantly repeated ejacu-
lations as "Oh God!
Kill me!" etc., which are
the expression of a per-
sistent depressive affect.
In those playing music
one finds repetitions
lasting for years of the
same figure {musical
verbigeration)
Thoughts, wishes and
hallucinations may also
become sterôtj^ped.
Some of the stereo-
type expressions have a
comprehensible content:
one will represent the
movements of a shoe-
maker because the lover
was a shoemaker; an-
other the balancing in
the quadrille because the
lover was met in a
first
quadrille. In two cases

snout cramp was the ex-
pression of contempt for
Fig. 32. Stereotype, catatonic attitude with
the surroundings. Usu- closed eyes. It imitates some complex of great-
ally the patients are not ness. The expression of the face is vapid.
conscious of the mean-
ing, and at least during the phase when stereotypes were present, I
have never obtained direct information about them. Only the asso-
ciation experiment, subsequent or indirect remarks of the patient, an
exact objective anamnesis, and similar things, can enlighten us.
5. Mannerisms.''^ Many patients assume certain poses; e.g. one
will for years try to imitate Bismarck; others want to represent
something else that is extraordinary, nearly always in a pompous,
artificial, caricatured manner. But sometimes only particular acts
are changed or over-embellished in some way: Before partaking of
food the plate is taken on the fork seven
struck three times, food is
times and thrown off taken into the mouth; in

again before it is
dressing, before making any slight movement, the cloth is rubbed
^ t
MB
I
d

Figs. 33a and 33b. "Snout cramp" in a catatonic with alternating manic and
melancholic days. Change of phase very decided, often from one minute to the
other, (a) on a melancholy day, (b) on a manic day.
several times; the patient walks about the chamber three times
before she sits down on it. In talking diminutives or foreign words
are used with affected intonation. To all words an "is" or an "ism"
is attached. The hand is improperly extended in greeting or only
the little finger is offered.
6. Negativism is a very frequent and very disagreeable symp-
tom of schizophrenia. When the patients should get up, they want
to remain in bed; if they should remain in bed, they want to get up.
Neither on command, nor in accordance with the rules of the hos-
pitaldo they want to get dressed or undressed or come to meals or
'
According to Ziehen "Variational stereotypes." (But all mannerisms
need not become stereotyped.)
*"
See p. 154.
.
\ leave their meals; but if they can perform the same acts outside
of the required time or somehow contrary to the will of the environ-

ment, they often do them. Of their own accord they do not go to
the toilet; if they are brought there, they hold back the excrements,
in order to soil the bed or the clothes immediately afterwards. They
eat the soup with a fork or with the dessert spoon, the dessert
with the soup spoon. Many resist all influences with all their mij^ht,
often with excited scoldings and fighting; thus negativism becomes
a source of attacks of rage. It can develop into a real impulse to
an active impulse to anger incessantly those about them
tease, into
in most ingenious manner; the patients hide their things
the
and then maintain that the orderlies have stolen them or
have not given them to them, etc. In some cases one can
with certainty bring the patient to do the desired act if one
forbids him to do it, or orders him to do the opposite {command
negativism)
Many patients are negativistic toward their own impulses (inner
negativism) ; as soon as they want to perform an act, an inhibition
or counter impulse appears so that they do not perform the simplest
acts like eating. The spoon is arrested half way up to the mouth
and must finally be put down again.
In purely intellectual matters also, negativistic tendencies are
very disturbing, since with every thought the patients must also
think the opposite: "I am in the hospital, no, I am not in the
hospital" (intellectual negativism). Even the voices can continually
say the opposite of what the patients want or think, or they can
recite the two contradictions.*^
However, even the most pronounced negativism is not absolute;
toward certain persons it is usually greater than toward others.
Often it only becomes apparent in the intercourse with the personnel
of the hospital, but not with the other patients. Sometimes it is
provoked when the complexes are touched.
Negativism is a complicated symptom. To a certain degree
"negative suggestibility" is a normal characteristic, which is often
disagreeably conspicuous especially in little children, in that they
reject all sorts of things. That negativism in, schizophrenics is
especially pronounced, may be due to a fundamental cause of which
we are ignorant. But it is undoubtedly connected with dereism
which makes every external disturbance felt as unpleasant. But
the understanding of the environment, the enduring of
deficient
counter measures such as the confinement, naturally produce a
" See also ambivalency, p. 286.
hostile attitude. Sometimes, especially in women, sexuality with
its marked ambivalence contributes its influence, and leads the
patients to reject what they really want.
The patients themselves can usually give no explanation of the
negativistic attitude. The explanation by means of voices or delu-
sions is naturally not sufficient because usually the reverse is the
case, in that the content of these symptoms is conditioned by the
existing negativism.
7. Command Automatism and Echopraxia. As an outward con-
trast to negativism there sometimes found in our patients an
is
automatic obedience to given commands, even when the patients

really resist, e.g. if one orders them to stick out their tongue and
threatens to pierce it. Be-
sides, in confused as in tv/i-
light states, echopraxia and
echolalia occur at times.
8. Automatism (including
compulsive phenomena). No-
where do we find automatic
action so frequently as in
schizophrenia and in the most
various degrees of connection
with the conscious ego.^^ Ap-
parently insignificant move-
ments such as lifting the arms,
assuming the position of the
Fig. 34. Grimmacing catatonic. crucified, screaming, then real
"actions" as breaking win-
dows, tearing clothes, smearing, often take place without the conscious
will of the patient. To be sure, occasionally it goes as far as arson,
murder, or suicide; some of these serious anti-social actions are per-
formed so clumsily that one gets the impression that an inner resist-
ance prevents the actual attainment of the purpose.
Automatic impulses may also change a normal willed action, e.g. a
complicated piece of knitting is made incorrectly against the will of
the patient who knows the pattern well.
Automatisms of speech lead only rarely in schizophrenia to com-
bined utterances; instead they sometimes produce incomprehensible
hodge podge. Verbigeration may also be classed with these as generally
the greater part of the stereotypes run off automatically. Coprolalia
often has the distinct character of compulsion.
"Comp. p. 150.
There is also a schizophrenic

compulsive thinking, a compulsive
remembering, even a compulsive
cessation of thought. Among the
affective disturbances compulsive
laughter is especially frequent; it
rarely has the character of the hys-

terical laughing fit, but that of a
soulless mimic utterance behind
which no feeling is noticeable. It
may often be provoked by allusion
to a complex. Sometimes the pa-
tients feel only the movements of
the facile muscles ("the drawn
laughter").
Contrasted with hysterics and
compulsive neurotic patients,
schizophrenics usually give little
thought to their automatisms. It

simply happens, they cannot help
it,and with that they are satisfied.
To be sure, some struggle against
it and feel the obsession, and still
more believe themselves possessed

and infiuenced by their persecutors.
In the latter case they not rarely
adopt defensive measures to pre-
vent themselves from carrying
them out, e.g. sticking a piece of
wood into the mouth to prevent the
Fig. 35. Manic schizophrenic
woman who has made
herself a
utterance of unseemly words. wreath out. of and twigs and
grass
The automatisms are to be con- besides holds with both hands the
lower part of her dress which has been
ceived as actions of the uncon-
twisted into the shape of a sausage.
scious; the complexes on which In bed she holds in front of herself
they are based can be often dem- the linen twisted in the same way.
Interest in the process of photography
onstrated in the analysis of acces-
conceals the otherwise rigid facial ex-
sible patients. pression.
9. Impulsiveness. Schizophrenic
impulsiveness is not a uniform symptom but a frequent method of man-
ifestation of the morbid actions which originates in different sources.
Some of the impulsive actions are automatic, others are aft'ective
actions, "unloading" in the case of an emotional tension in which the
patients feel more and more uncomfortable. Something must then
give way; they scold or fight or tear up only to quiet down after
minutes or days. With this may also be included the ''explosion in
prisons" observed in latent schizophrenics. In the same way the sud-
den outburst of rage, which is frequent in schizophrenia, leads to im-
pulsive acts. Many sudden acts are based on the disturbance of asso-
ciation; it is a case of unmotivated notions which are carried out'
without resistance.
({}) Acute Syndromes. The course of schizophrenia is frequently in-
terrupted by acute appearances of entirely different manifestation and
origin. To these belong: Shifts of the pathologic process, frequently
with catatonic-hallucinatory or stuporous manifestations; simpler
exacerbations of the chronic condition, mostly with paranoid or cata-
tonic syndromes, abnormal reactions to emotionally toned experiences,
especially in the form of hysterical twilight states or attacks of scold-
ing. A
part of the manic or melancholic displacements of mood are
probably by-products of the morbid process. Then also there are
naturally conditions that do not depend at on the disease
all directly
but complicate it or at the most are released by
it, as perhaps periodic
moodiness which may belong to an accompanying manic-depressive
insanity. The acute appearances may last hours or years. Severer
forms also, that give the impression of independent psychoses, may
break out suddenly, one might say from one minute to the next. An
exacerbation of the schizophrenic process favors the appearance of
psychogenic symptoms; thus the manifestations combine indiscrimi-
nately.
Melancholic and manic states often constitute the first manifest
syndrome of the disease, but they may also supervene later. They
usually last months or years and appear as a combination of the melan-
choly, or it may be a manic triad with schizophrenic symptoms.
The depressive affect in this case is frequently combined with
anxiety, but it appears rigid, and superficial, the utterances being ex-
aggerated and often pathetic; the delusions strike one as altogether
too senseless. Occasionally one finds a combination of senseless de-
lusions of grandeur with the depressive delusion. The disturbance of
thinking is very ex-treme and may lead to an absolute monideaism,
which probably does not occur in simple melancholias.
The manic states are similarly characterized. The fresh joyousness
of the manic is lacking; outbursts of rage often appear completely
unmotivated. The rigidity of the affects is particularly noticeable in
this case. With the flight of ideas one observes dilapidation, and
bizarre schizophrenic associations. The manic pressure activity

readily becomes an incomprehensible pressure motion; silly tricks may

be added to the peculiar actions. Hallucinations and delusions are
generally present. But the delusions are usually more flighty than in
the depressive states.
Of special importance are the acute catatonic pictures in which
catatonic symptoms mingle indiscriminately. In akinetic forms of
move little or not
attonity, of stupor, of flexibilitas cerea, the patients
at all they do not take care of themselves, let the saliva dribble out^
;
never swallow spontaneously, and soil themselves. Peculiar poses are

sometimes retained for a long time. Usually complete mutism exists.
But such conditions are now and then amenable to temporary psychical
influence so that an act may be performed or an answer given. Mutistic
patients at times make themselves understood in writing. Often this
is accompanied by a coated tongue and fuligo. Vasomotor symptoms
most frequently and severely, complicate just this picture.
In the pronounced hyperkinetic forms the patients are in motion
day and night:
They climb around, turn somersaults, hop over the beds, knock
twenty times on the table, then on the wall, balance themselves, bend
their knees, throw themselves into the air, strike, destroy, force the
arms in the most twisted position possible between the radiators of
the heating apparatus, and they are unmindful of burns they scream, ;
sing, verbigerate, scold, laugh, cry, spit, make faces, sad, terrible, or
cheerful; they take any object move it in any way
into their hands,
at all, lay it down in another position and make a thousand other
movements, of which, to be sure, the individual patient usually limits
himself to a certain number. The movements
are always somewhat
abnormal. an object, they do it in a particular
If the patients lift
way as it is not ordinarily done; they climb into bed from the head
end and with most unusual acrobatic flourishes or they let themselves
fall into it, etc. The movements are often made with great strength,
nearly always with the exertion of unnecessary muscle groups; in-
difference to themselves sometimes appears as great as that toward the

animate and inanimate enviroment. Many patients are also always
in motion but it is slower, more clam-like, and more dream-like. The
akinesis may be interrupted by sudden catatonic raptus, in which the
patients do some kind of harm, from the breaking of a pane of glass
to a brutal attempt at murder or suicide. Analgesia often increases
the danger and indifference of these patients, to themselves and others.
In severe catatonias the psychic state is usually altogether unclear.
Many give no account of themselves or even lie in a complete dream-
world. The affectivity is usually difficult to make out. Often there
are indications of various contradictory feelings but none seem to pene-
trate. Subjectively also no describable mood exists except a frequent
indifference.
The buffoonery syndrome is not always easily separated from cata-
tonic states. In this syndrome the entire picture is taken up with
playing demonstrative striking tricks, and with giving wrong answers;
like the Ganser twilight state it probably only occurs as a reaction to a
situation from which unconsciously one wants to escape through
insanity.
If in an acute appearance hallucinations and delusions prevail
to the extent of fully disturbing clearness, and if the catatonic
symptoms are absent or insignificant, we call the condition schizo-
phrenic insanity. Here the affectivity is usually less injured than in
the preceding group. The mood frequently has definite coloring and
is often slightly modifiable.
In the face of unbearable situations, most frequently in disap-
pointed love, schizophrenics retreat into a twilight state; the un-
pleasant reality is split off and exists for them only secondarily; in its
place another world, frequently with frank wish gratification, is imag-
ined. The patient marries her lover, he visits her every night, she
becomes pregnant and bears a child. But not nearly all of these
patients are happy. They cannot flee entirely from reality and, con-
sequently, come into conflict with it outwardly. Shutting off succeeds
most intensively, and the imagined happiness is therefore least dis-
turbed in the religious ecstasies.^^
The behavior of those in the twilight state varies. Some live their
dream quietly in bed or even under the covers. Others stalk about
like ghosts inan unintelligent manner, as they have a false conception
of the environment and hence get into conflicts. Invariably double
orientation plainly exists. The outcome is usually by lysis. While
the twilight states in hysteria or epilepsy usually last only hours or
days, the schizophrenic sometimes extend over months, under certain
conditions into the second year. Nevertheless, corresponding to their
origin, they much more rarely leave behind a serious aggravation
of the permanent condition than do other acute syndromes of the
schizophrenia. In prisoners held for examination, but occasionally in
other cases, the condition manifests some signs of Ganser's syndrome.
While the twilight states are formed on psychic foundation, there
is a form of "unclearness" which has an organic character and has
to be noticed because of its particularly bad prognosis. The patients
are in an unclear twilight state, they do not let themselves be aroused
^See p. 113.
by psychical influences, in spite of the fact that one is in intellectual

contact with them, and they often make every effort to answer our
questions. The train of thought is slow, unclear and fragmentar>\
These patients fail even simple calculations; in writing they un-

in
willingly make orthographic and grammatical errors, contractions,
contaminations, etc.: at the same time hallucinations and disturbances
of orientation may be lacking. Affectivity also may be relatively well
preserved. Nevertheless the condition is very difficult to distinguish
from the more psychogenetic forms.
We still have to mention states of confusion in which the incoher-
ence of the train of ideas dominates the whole picture, and where one
observes exogenous and endogenous attacks of rage, delirious syn-
dromes, and states of wandering (fugues), at times as a result of a
special brain disturbance, at times more of an hysterical nature or as
a reaction against unpleasant experiences or merely as a pathological
fancy. A considerable part of army deserters are schizophrenic wan-
derers. Dipsomanic moodiness may also appear occasionally on a
foundation of schizophrenia.
D. The Subdivisions
Although schizophrenia is probably not a homogeneous disease, we

are not yet able to divide it into natural subdivisions. Nevertheless
in order to orient oneself in the external forms of the constantly
changing morbid picture, four forms have been distinguished, accord-
ing to the presence or absence of definite symptom groups. They are
not nosological units and from patient to patient and in the same
patient pass over into one another, so that a schizophrenic may be
admitted into the asylum, e.g. as a hebephrenic, may remain there
for years as a catatonic and may finally be released as paranoid. But
most patients remain permanently within their group.
1. Where delusions and hallucinations the two symptoms usually
go together in schizophrenia are in the foreground, one speaks of the
paranoid type or dementia paranoides.^* The paranoid type can de-
velop after any melancholic, manic, catatonic acute initial onset (''sec-
ondary insanity" of the older authors), or can begin immediately as
such. In the latter case the entire course is as a rule chronic through-
out. During a stage of discomfort in which ideas of reference grad-
ually become more definite, there develops in the course of years a
**The latter term, up to the eighth edition of Kraepelins manual, does not
mean all paranoid forms of dementia praecox but a particular sub-group which
quickly forms confused delusions but no catatonic changes of the external
attitude.
complicated pile of delusions, which are only connected by the general
tendency of persecution or (much more rarely) of grandeur or of
hypochondria. However, the beginning may also manifest itself by
finished primordial delusions that seem to come from a clear sky,
which then increase and are only later followed by distinct ideas of
reference and hallucinations. Many of the patients keep out of
asylums for a relatively long time, others alternate between freedom
and commitment, and others again lose the external control so early
and so severely that they have to remain in asylums the greater part
of their lives. Especially in the last, single or even many catatonic
symptoms very easily complicate the picture.
To this class belong some of the litigious schizophrenics who de-;
mand police protection against imagined injuries, and in spite of all
refusals cannot cease with their complaints. Others may be classed
as cases of simple schizophrenia because their attitude seems to rest
more on the determination to be always right than on a real delusion.
Some of the cases mentioned by Kraepelin among the presenile
delusions of injury are according to our conceptions belated paranoid
forms.
Paranoid. Railroad employee. Medium intelligence. At first
spinner, then railroad worker where he rose to train conductor. Al-

ways particular, silent. Toward the end of the thirties he began to
be mistrustful toward his wife. At the same time a better position
with the owner of a factory who was a free-mason was offered him by
intimation from a workingman who was very "sympathetic" toward
him; finally other positions right in the lodge were also offered him.
Years ago he was supposed to have seen a free-mason in a compromis-
ing situation (in reality a woman had merely entered a railroad com-
partment after him) some allusions were supposed to be made to it
;
in the newspapers. But he had kept quiet about it and now the free-
masons want to reward him for it. Because he did not accept the
reward, they persecute him. Furthermore years ago he once made
unfavorable remarks about the free-masons. All sorts of things are
said to him on the street in passing; remarks are also made elsewhere
which he only understands later. At night he hears voices. In a
mysterious way his thoughts are read. The free-masons are after
women; they use his wife also. He demanded from her with threats
the money that she had obtained in that way; once he wanted to cut
open her stomach with a razor. His sister-in-law is sometimes pale
and sometimes red; that is on his account. Theatricals and thoughts
are made for him while awake and especially while dreaming. During
the night he is questioned; only in the course of the day does this come
into his consciousness. Because he maltreated his wife and did not
work any more, he was brought into the hospital. There he showed
the same picture for years, at time quiet and capable of work, at times
in milder excitations with scolding and incessant complaining about
persecutions. All sorts of poisons arc put into his food; he feels them
working body; they want to murder him; especially at night,
in his
sperma, human blood, urine, "pollen," and horse manure are put into
his body in various ways; one spits into his mouth; one hypnotizes
and magnetizes him, and brings him into a "latent" state where one
cannot breathe. The people here have a staff like a magnet staff;
with this they make him powerless, rob him of his potency. They
want to castrate him, extract his semen, cut up his lungs, smash his
urethra, distend the sexual canal, cut up his buttons, bum up the inner
sexual organs, and pinch him all over his body. Voices threaten to
cut out his eyes; against his will, his daughter has been admitted
to the masons; he is accused of having used her in various positions;
the government, the church, the whole international society, his wife
and his own mother and the physician are combined with the free-
masons; the physicians have obtained millions to hold him in the
asylum; he, himself demands 30,000 fr. damages per day for the con-
finement and he figures up everything exactly. He keeps a record of
all the hallucinatory maltreatments; they demand that he become a
free-mason; he does not want to and therefore they persecute him.

At other times he wants to become a free-mason but then they will
not admit him at all. For a long time he said in a stereotype manner
to everybody a hundred times a day, "If you please," by which he
meant to say on the one hand nothing, and on the other, he put various
interpretations into it. He should be admitted to the free-masons or
he should be permitted to have intercourse, etc. When he sees a
woman, he is compelled to prove his potency; then he can join the
masons. Then he can only be prevented by force from undressing
himself. He wants to enter an a\aation race from Petersburg to jMos-
cow, he invents flying machines, improves trolley cars, makes count-
less contributions to the physicians and officers of the hospital. Once
he tore away a toe nail because the scissors were not good enough to
cut it off. For a large part of the time the patient is in the quiet
ward. He shakes hands with visitors in a friendly way, even though
often with a slight, superior smile.
Schizophrenic Litigious Woman. Excellent worker in a hat busi-
ness. Was a good pupil but wanted to get somewhat higher up in
the world; as a farm girl she attended a vocational school for women
to learn finer work. Then she had various places as cook and house-
maid; at thirty-two she was housekeeper for a doctor who was just
establishing a practice. Now she affirms that on the very first day
he became intimate with her and promised to marry her. The further
details are still more improbable or entirely impossible. His relatives
wanted to prevent him from marrying her. He should make an ar-
rangement with her. On the first day he told her she had the right
to object if he married. (These can be only memory deceptions.)
She would have to make good her claim or be silent. After about nine
months the physician discharged her, according to her version, because
the people were talking too much about their relations. She then
worked in different places, at last mostly with a hatter and from time
to time reminded the physician of his promise. When thirty-four
years old she once had a headache, pains in the eyes, an "attack like
a stroke," trembling all over the body. She was treated by the physi-
cian who was supposed to have renewed his promise. When thirty-six
she read the announcement of the physician's marriage. Then she
demanded "her rights or a good payment" and took a position in his
neighborhood. He was supposed to have had a simple wedding to
indicate that he really loved the patient. Then she wrote to him
frequently, called him names and then also preferably his wife, at
last on post-cards. "Jail-bird," "shabby hotel frequenter," "whore,"
"Mrs. Louse," are among the better expressions. She became unre-
liable in her work and even when she made big mistakes she claimed
to be right. Then she began suits in all the courts which naturally
could not entertain a complaint without evidence of probability, when
it concerned entirely abstruse demands. The courts were then vilified:
"His Honor the Judge is idiotic." Finally the physician was com-
pelled to sue for slander whereupon the patient was examined. Dur-
ing the examination she was absolutely incapable of discussing her
complaints. She was not fully certain of the time sequence of all her
experiences but otherwise she had a good memory and good orientation.
She recounted impossible assertions of the physicians and the judges,
who had said she was right (memory deceptions). She really did not
want anything from the physician "she only wanted the physician's
wife to have a chance to get away with an honorable reputation."
Since the physician did not answer, he admitted her claims. Either
he had to do that publicly and send his wife away, or he had to dispute
it and keep his wife." She stoutly maintained that as long as he
made none of these declarations, his marriage was void and his wife
was a concubine. The doctor had made her (the patient) a promise
of marriage that held for life; with the other he was only engaged.
She was incapable of seeing that the doctor's wife was entirely inno-
cent toward her. Presented at a clinic she began at once to talk about
her affair, taking for granted that the auditor knew everything. Of
course she had to be pronounced irresponsible; she was placed under
a guardianship and released. But she did not want to accept the ver-
dict or pay the trial costs which led to a number of scenes with much
noise and spitting at the marshal, etc. She scolded us too in various
missives. Nevertheless she was not brought in for four years until
she forced her way into the police station, made a big scene and, after
being thrown out, continued it with increased energy. It was reported
that she had worked regularly and had spoken sensibly about indif-
ferent matters. But as soon as she touched on her affair, she became
confused, excited and hard to understand. She did not want to work
until she was put to bed and ordered to cease her written litigations.
There she pulled herself together and after a stay of six months could
again be discharged. But in the following year she came back be-
cause she had made a scene before the justice of the peace and prom-
ised she would do it every day until the doctor was summoned to court.
This time with us she did not cease her protesting, made a lot of noise,
ran after the physician in her shirt in order to scold him. She was
taken out by the poor relief society, which should long ago have taken
charge of the impoverished invalid, and as yet she has not returned.
Her last greeting was: "Sow dogs, sons of bitches, alienists send me
my clothes to X. St. ... promise of marriage belongs in the courts.
,
I will reproach the poor relief society until the matter is brought to
court." Hallucinations were not observed, on the other hand many
illusions, perhaps also memory hallucinations. She also told many
things about us that we had never done; e.g. that the physician in
charge of the division had said that she did not belong in an insane
asylum. The schizophrenia shows itself, among other things, by the
confused nonsense of her representations in court, the absolute in-
capacity for discussion and also, by the decline of the strength to
work, and by the occasional incapacity for discussion even in her
work.
All this counts all the more because she was formerly intelligent.
2. If catatonic symptoms are permanently in the foreground the
picture is called catatonia. A large part of these forms begins with an

acute attack; under certain conditions the psychosis is revealed from
one moment to another, other cases begin with a chronic attack, with
some catatonic peculiarities, e.g., mutism or mannerisms, and remain
chronic, while in others chronic and acute conditions alternate. Fol-
lowing acute catatonic attacks a tolerable condition may again recur;
the cases that begin furtively all have a bad prognosis without any
remissions that are worth mentioning.
Catatonic State. Nineteen years old. At first a bar-keeper; then
he worked in many different places; at last in a dye factory. In spite
of the fact that he was a Catholic, he had recently joined the Salva-
tion Army. He came into a meeting in shabby, dirty clothes. He
began to pray but very incoherently. He had learned something
wonderful; Noah's ark was coming; he was compelled to speak. It
was difficult to silence him. Then he had previously run
told that he
after the sun. In the factory he had refused to touch any other
colored silk but white. Some days later he came to a musical re-
hearsal and began suddenly to read a psalm. He was requested to
be silent. Suddenly he stood up, stood in front of the others and
said with a staring expression: "Do you believe that the devil is
tied? Do you believe that the devil is tied? He is tied; he is tied."
He repeated the last words several times, becoming louder each time.
When he saw that the others did not join in, he exclaimed: "You are
enslaved; tomorrow I will go into the heart of the city and begin
to pray." Then he became quiet again. The following day he did
not come to dinner and began to pray in his room with a roaring
voice. At night he went to a friend's room, stood there rigid in a
peculiarly twisted pose, the one arm stretched out straight, the other
held over the head, and made a stiff, peculiar face. Then he suddenly
wanted to write memorandum book. When the latter
in the friend's
refused, he called him Judas. Had he come to betray Christ with a
kiss? He tried with all his might to kiss him. He then got down
on his knees and began to pray in a dreadfully loud voice. Getting
up suddenly he said: "Now all is over," and had a normal expression
but immediately continued that he was crucified, he had been called
for something special, he was Christ. He told that when he was in
bed a spirit had come from above and another from below, and a great
power had come over him. He demanded that all present eat of his
bread. Then they would understand him. When brought to the
clinic, he quieted down quickly, became half aware of the impro-
priety of his conduct and thinking, but remained indifferent, did not
want to leave the asylum, and had to be transferred to another.
Depressive Catatonia. Continuous hearing of voices. Teacher,
who had previously seemed quite normal. At thirty-four for the
first time he was irritated and sleepless, and occasionally had dizzy
spells for a year; then there was a delirious stage. After a stay of
twenty-eight weeks in a sanitorium he was "cured" After a year
and a half he had a similar attack. Then he was once more a good
teacher, felt well and cheerful. During a trip to Tyrol with friends
when forty years old he felt that his ideas were getting hazy, he could
not speak any longer, and again entered the sanatorium. Here he
was in a stupor most of the time and believed they wanted to bury
him alive. He had many hallucinations of hearing. He believed his
dreams were real experiences, ate poorly, vomited. After a temporary
improvement in the fifth month he wanted to go through the window,
and reproached himself; at the command of the voices he threw his
wedding ring out of the window, whereupon he was taken to the clinic.
Here he lay m bed in a deep stupor, maintaining a peculiar position.
He saw pictures on the wall, children and women, who were kissing;
but most of all he heard voices and felt that something was being
done to his body. He had threads about his hand, especially on the
ring finger, that drew together. His penis was being operated on
'so that the indecent sensations would disappear." The voices tell him
that he had denied his God and had perpetrated a lust murder. "Lust
murder is sexual desire." He is not a human being; he is decapitated.
Depressed but rigid expression. Catatonic raptures; jumps up sud-
denly, breaks a window, etc. After eight months' duration of the
attack there was a sudden reversal to a euphoric mood and orderly
conduct: he spoke and wrote of his gratitude to his creator and the
physicians, of how he was drawn to his home, how unutterably glad
he was to stand again in the school room, a disciple of Pestalozzi, of
the bursting energy of youth, and the plans of a returned spring tide,
etc. But he did nothing to get out. Eleven months after the begin-
ning of the attack he was discharged, took up his school work and for
six years always remained euphoric and apparently a good teacher.
Since then a similar attack, lasting only three months; then he re-
turned to his former state. The voices warn him in school when he
want to say something silly. Thus, objectively and subjectively, he
gets along well.
Manic Catatonic. Unmarried woman, a chambermaid from a
psychopathic family. much. Twent^'-nine years
Intelligent, has read
old. After her mother's death she suffered from over-exertion and
money losses. She believed falsely that a cousin wanted to marry
her and always waited for him. After several months, manic excita-
tions occurred which increased during eight days. She sang in an un-
seemly way, wrote a note to the effect that her brother-in-law should
not bother her all night. Violent. She said she had to die all the
time and was not being buried. She believed all men wanted to do
her violence. Following moods of marked excitement, she cried. In
the reception ward of the clinic she lay down on the floor and de-
scribed a beautiful vision (ecstasy). Nevertheless she permitted her-
self to be diverted, and then she became completely oriented, felt
very happy, declaimed that she had faith, which would help her with-
stand all trials, etc. She spoke in the same tone of the fact that she
wanted to die; in the bath she tried to dive under the water. Then
again for some time she remained rigid, the arms stretched upward,
with a tense facial expression. When touched she jumped up enraged,
stuck out her tongue, etc. ;
pronounced flight of ideas. At times the
schizophrenic element could not be recognized in the manic; then
again pathetic expressions that were repeated endlessly. The nurse
was sometimes her brother, at others her sister and at the same time
a third person. She was most quiet when isolated. Tore up a great
deal. Indications of negativism; did not shake hands with the physi-
cian but handed him her cup that he should hold it. For a time she
climbed about on the edge of the bed with a tense face and tightly
pressed lips (she later maintained she had to play the part of a
monkey). In the room she ran around in a circle, waved her hands
to keep time. She has been made insane by powders; she was being
electrocuted. After a while she quieted down; after six months she
could be discharged, and by outsiders was considered cured. After
another six months she returned in a similar condition. Now she be-
came rapidly demented. Though she remained euphoric but irrespons-
ible, she breaks windows, tears things, fights, turns somersaults, hears
many voices, and becomes less and less capable of doing the simplest
task. If one has voices, one calls it "Stirking." The voices say that
one should "stirk," that is, one should "rattle" the windows.
Catatonia with Religious Delusions. A farm hand, twenty-one
years old; came to the asylum because he had assaulted the minister of
his village, as he declared because the minister had designated his own
son as "Messiah," while the patient had in the last few years "under-
gone the Messiah's suffering" and now wanted to be the real Messiah.
The patient had been a quiet, not unintelligent boy. A few years
previously he had become pious, went often to the minister and re-
cently had told, in writing and orally, of visions (angels, Messiah, and
God). Once he demanded urgently that the minister change his
(patient's) name, that is, take him as his son. In the asylum he at
first spoke much of the minister and his family, but chiefly in another
sense; even since his school days he had been in love with the minis-
ter's daughter. The angel materializations have the features of his
daughter. The God materializations resembled in part the minister,
in part the patient's grandfather. As Messiah he had the right of
sexual intercourse with several women and with all the minister's
daughters and also with his wife. Once he saw himself married to
the daughter. Once the voice of one of the daughters called: "Oh,
that he would kissme with a kiss from his mouth." Later he halluci-
nated the daughters as being successively in his bed and having inter-
course with them, wherein he experienced heavenly raptures. Occa-
sionally he was also "Priest King" which signified possessor of the
minister's daughters. But he felt the minister's resistance more and
more. Hethought the latter wanted to leave him only his wife, and
himself beget a Messiah with the daughters, so that the Messiahnic
dignity would remain in his family. In materiahzation he saw the

Fig. 36. Chronic catatonic women. Both react to the taking of the picture
with a sidelong glance. The patient at the left has a pronouncedly compressed
mouth. The one crouching at the right half closes her eyes. The entire picture
(aside from the attention to the picture taking) is one of continuous repose.
minister's daughters pregnant. A voice told him he should assault

the minister. Finally he was impelled by the spirit to take a club
and strike the minister, "because he would not let him have his daugh-
ters." In this connection his arms raised automatically. As usual
(or always?) the morbid religious aspirations are a symbol of sexual
strivings. In addition another complex was satisfied: Tuberculosis
raged in the family and the patient himself suffered from lung trouble ;
the penetration of the spirit within his breast at times made him well.
The patient very quickly wove himself into his sexual religious
phantasies, stood mute for several years in peculiar positions and
died five years later of tuberculosis.
Catatonic after Castration. Wife of a physician. From a family
of high standing but somewhat peculiar. At nineteen a fall from a
stair. "Traumatic hysteria" of short duration. Engaged at twenty-
two, while taking a walk she wanted to jump into the water because
of a little discussion with her fiance. During herfirst pregnancy often
depressed. Bladder and bowel trouble without apparent cause. Always

particular, but cheerful, was a little afraid of housework, excited
when contradicted. At
twenty-eight "hysterical ovary trouble," later
ovariotomy because of bilateral cystic degeneration with a normal
recovery. At home after eight days she acted as usual. Then went
to a resort to recuperate from which she returned depressed: She
could no longer be a real woman and mother, she was a perjurer, jus-
tice was pursuing her, she saw and heard the district attorney, etc.
Attempts at suicide. Then stupor, mutism, refusal of nourishment;
at intervals there are times when she speaks normally. After several
months she came to the asylum: mutistic but going about excited; at
times she took the physician to be her husband, at times for the
asylum physician. She heard her mother and children in the corridor.
Rigid position for days, staring into the distance, mutistic. Between
times excited, strove to get out of bed to the window or the wash-
stand. Refusal of nourishment. Sees a horse's hoof. After a few
days suddenly pleasant, clear concerning the environment, sensible con-
versation but often sudden obstructions. From now on continuous
change of condition: sometimes quietly inhibited, at others excited;
also clearer moments with conversation and music. She wants to write
but sometimes does not get beyond the beginning. Expresses sometimes
love, sometimes hate for the physician, both with a strong sexual ele-
ment. Often retention of urine to the extent of catheterization. Fre-
quent refusal of nourishment. Always many voices; her husband's
head has been knocked off; she is at the North Pole; especially frequent
is the idea, "I have been robbed; everything has been taken away from
me, my money, my name." She feels a key in the genitals, wants to

take the keys from the nurses. Her husband is married to the nurse.
Then for several months incessant change between timid agitation
with frequent violence, hits and bites, mild stupors. Scratches her face
and feet. Special agitation on the anniversary of her marriage and
on the anniversary of her last attempt at suicide. Later negativism,
marked shrewishness, rigid face, uncertain walking, back and forth,
usually without any purpose, then again times with verbigeration:

"he, he, he, now" or "no, no" or "dc, dc, de." After sixteen months
she was discharged at first to a physician, then home. There she was
very changeable, at times cheerful and apparently normal, then for
hours verbigerating while walking up and down stairs; ran to the street,
spoke to strange children as her own, then for days excited, violent.
In the meantime at the table she can be the hostess to perfection.
Sometimes unclean. After nine months she returned to the asylum
where for years she has been very dissociated. Her mood is usually
elevated but rigid. She is married to the doctors and all the other
men of station. Goes through countless confinements. The nurses
are at times her daughters, at times the wives of her husband, and
should, therefore, be beaten. She prepares for her engagements to be
married, in that she paints her eyelids and brows with shoe-blacking.
She dresses her hair peculiarly. She has an engagement to sing
Mignon. At other times she is continually under the bed-clothes.
Memory deceptions: The nurse once had an affair with her husband.
Patient has once been proclaimed queen of Switzerland at Basle. Fre-
quent mistaking of persons. After a while she became incapable of
any work; nevertheless at intervals she still has good days when she
occupies herself somewhat. Psychologically it is interesting that she
always was peculiar. Her husband was ambivalent to her. (Attempt
at suicide while taking her first walk with him. Depressions when
her first child was born. Later her husband has been beheaded, has
other wives. She has other husbands. When visiting she is hostile
toward him, when staying at home she is usually very kind.) Hys-
teroid troubles of the ovaries after the fall, and after the births. After
the castration there was an aggravation clearly connected with the
mutilation; she no longer a woman, no longer a mother. She has
is
been robbed of everything, of the keys also, which are the symbol
of the power of the house-wife but at the same time evidently of the
genital of the man and of the man himself. The nurses have robbed
her of the key and they have robbed her of her husband; these are
identical for her. Then we observe the compensations: She marries
the most distinguished men; she bears countless children, becomes
young again as Mignon, becomes queen of Switzerland. Excitements
during commemoration days.
Catatonia with a Cycle of Two Days. Intelligent girl, but always
reserved, after puberty to a striking degree, in spite of a cheerful dis-
position. At twenty-four an apparently happy marriage with a very
patient man; but she herself was stubborn and irritated. At the birth
of the third child, being thirty-eight years old, a melancholic condition
with ideas of sin ; she had not taken care of the child. At forty-seven
she lost her husband; for the first few days there was no reaction.
Then two weeks in which she remained prac-

a stuporous condition for
tically motionless, then changed into melancholia with unclear, frag-
mentary ideas of sin, she was being punished; heard many voices; very
rigid expression; at intervals cataleptic; then attacks of fear with noise
and a striving to get away. About a year later the patient begins to
alternate regularly with days on which she is negativistically rigid

and stubborn and others on which she is relatively approachable and
pleasant, sits at the table and pulls silk. For a long time there was
a three day cycle instead of a two day, there was one depressive-
stuporous day, one irritable day, and one euphoric. Otherwise the
two day cycle has lasted twelve years. Besides there is a negativism,
varying in degree with different persons. She tries to shake hands
but withdraws again; she is erotically jealous when others are greeted
pleasantly; she is married to the physicians in the asylum. Very-
brief associations. An attempt to take her home had to be given up
on the second (irritable) day.
Catatonia with Rapid Dementia. Teacher. The mother was tem-
porarily and is now again in an asylum; in the interval latent schizo-
phrenia for about twenty years. The patient was always somewhat
peculiar; at school uneven; many pranks; kept to himself very much.
Busied himself with different problems, such as socialism, and Schiller's
Robbers. Was apprenticed to store-keeper but did not stay long.
Then worked in various places. Once for nine months in a business
school, then he went to a high school. Once went suddenly to Berlin
where he stayed a month without doing anything. Then he entered a
normal school in another canton, where he managed to stay for the
final examination (age twenty -two). At first he was a teacher in a
private institute, then in a primary school which he had to leave be-
cause the pupils did not learn anything and "had nose-bleed if he
merely touched them." Then he wandered about Ziirich and was
arrested and brought to the clinic because he broke into a tramway
station to sleep there, although all his brothers lived in the neighbor-
hood. At first he was entirely indifferent, then much excited. Pre-
sented at the chnic he came in laughing loudly with his hand to his
nose. During the recital of a story he saw on the table the story of
the "Miser's Piece," and then wove a disconnected word mixture with
the word "Miser." When coaxed he becomes quiet, lets himself drop
heavily into a chair, sits there disinterested. Then he rocks on the
remains rigid and stares in front of
chair, smiles to himself, suddenly
himself. Then he gets up, makes
a lot of noise, sits down. When
I described his conduct he remarked: "That is so." At the mention
:
of word mixtures he added, "It is an Italian ox-mouth dish. The only

thing in the room is worms. I am the director of the seminar. ("Where
are we?") In an evolving hemisphere. C'est monsieur Jardin. I am
a patient. That is a palandes versus plassus." Stands up and stamps

hard on the platform, screams in an oratorical tone: "Oh, my dear
Blapsen, you are my dearest Klapsen." He must go away he walks ;
away singing quietly, "One has left." Hops down from the platform,
makes a lot of faces, lies on the floor, permits himself to be shoved
and smiles blandly. After this he remains mostly quiet, and mute;
he stays in all sorts of positions, partly in bed, partly up. Makes all
sorts of faces. Once he urinated in front of the toilet-door; then he

made a and prattled absolutely disconnected nonsense. To a
noise
visiting schoolmate he never said a word. Once he fell down sud-
denly and lay there quite rigid for some time; flexibilitas cerea. Then
again he made extremely affected speeches of incomprehensible word
salad. After a while he became quieter, sat around, sometimes verbi-
gerating. For a long time he asked the visiting physician the stereo-
type question "Isn't Aunt Grite coming yet?" To the aunt he wrote
:
Today, in the seventh

-
of July, 1914.
To our dear Aunt Grite
from
Hans Jacob and Max.
Dear Kind Aunt Schiifeli:
hope you no longer have to work so hard for the capitalists in St.
I
Gall; because here in Burgholzli (hospital) I still hope to find in the
socialistic centre of the world in Ziirich

wiedikon, a position as upper
grade teacher for Italian children although I was brought here against
;
my will per (police automobile) "by the watch dog of clericalism for
the Zurich ministers (K)" and here I have to perform work of not
the least use; although it is known that I am a licensed practicing
teacher of the Swiss Confederation.
Brother Hans has helped me in forming the sentences of this letter
as he you are aware a very faithful abstinent resembling you

is as
personally and individually more than I.
Signaturely I can only then excuse it as I got here in a milieu, in
which my own love of nature was violently stolen only with technical
devilish means and in contradiction to the laws of the milieu. So
long as I don't get the power over these "accursted" laws and condi-
tions (As Hans calls them) I can accept them only hypothetic ally as
technical-devilism."
Chronic Catatonia. A
good house-wife of retiring disposition,
marked by few speak less and less and in the
peculiarities, begins to
course of a few months ceases to speak altogether. Notwithstanding
this she takes care of her housework ver\'^ properly for another year.
Then other difficulties appear: she becomes irritated, untidy; nega-
tivism prevents her from doing just what she should do, or she does it
wrong. In the hospital she at first works very decently, keeping silent,
but loses more and more weight, becomes more negativistic, unclean,
tears things up, begins to fight and after about three years sinks into
a state of stolid negativism so that she remains only an object of care,
and rather difficult care at that. Among other things she had taken on
some mannerisms, had some hallucinatory excitements in which she
scolded loudly.
3. Schizophrenics with accessory syrrvptoms of different kinds and
varying strength have retained the old name Hebephrenia, although
it no longer fits the present conception.
The Kahlbaum-Hecker Hebephrenia was a dementia which began
relatively quickly at the time of puberty ; it usually ran
its course with
various affective disturbances, e.g. it began with a manic attack, and

besides, as was supposed, was further characterized by the symptoms
of callow youth, that is affectation, pathetic expressions and mimicry,
delight in boyish pranks on the one side, affectation of mature wisdom

and the desire to be occupied with the highest problems on the other.
But we can also find these symptoms in schizophrenias of other varie-
ties that break out late, if their complexes signify an attempt at self-
elevation and being great.
In the present conception of hebephrenia the age of the onset is
unimportant, even though most of the cases become sick during and
soon after puberty. It now constitutes the big trough into which are
thrown the forms that cannot be classed with the other three forms.
Hebephrenia with Manic and Depressive Attacks. She had lost her
mother early and was brought up in an institution where she remained
as an attendant. Always retiring and rather particular but with pleas-
ant manners. At thirty-six, when the father had to be taken care of,
she reproached herself for not doing enough for him and that she had
sinned by him. There was no improvement after a stay at a sani-
tarium; thoughts of suicide; once she stole around a fish pond, re-
mained all night in the woods and then returned unobser\'ed to her
asylum. When brought to the clinic, she at first seemed rather stiff
and apathetic, then depressed, but complained that she was the poorest
of all the inmates, lost and abandoned by God and man. She did
not sleep and was confused in the head. The upper part of her face
looked depressed, the lower was rather smiling. She showed frequent
obstructions. There were many voices. Stereotype striking about
with the arms. She identified various things, e.g. the different physi-
cians with one another. She was only three days old. The first day
was "when the first immoral act occurred" as a small child, "the second
corresponded with the second immoral act, the third is the present
when she has to die." She is also "here three days or three weeks."
The director of Burgholzli is also the head of her former institution.
Whomever she sees now, she has seen previously but as another person.
All mankind must become different (probably first as a very small
child). The body is poisoned. She will be murdered and the mur-
derers will go unpunished; at first she will be put in hot water and
then cut into pieces. Her sins have earned immortality for her. In-
cessant voices concerning which she can give no account. Obstruc-
tions. To indifferent questions she gives prompt replies. Many
paresthesias of the intestines. In the course of a year gradual im-
provement up to complete capacity for work. Two years later, twenty-
nine years old, there was a manic attack, in which she gossiped about
her relation with the director of the institution so that he lost his
position. As a manic depressive she was brought from another insti-
tution to us but after one month she could already be discharged. A
year later she returned in a manic condition after having been at
different places. She states she had worked too hard, had had stomach
bleedings, had been contradicted too much; she wants ever\^body to
obey her. Rigid mania with dancing and singing, tearing of clothes
and scolding. But her face does not change whether she jokes or
scolds. After half a year she could again be discharged and remained
away fourteen months. Then she merged in a new euphoric mood
with great indifference toward the commitment and everything that
happened or was said to her. At times she was extremely manic,
noisy, smearing and tearing. She began consciously to annoy physi-
cians and nurses. At intervals she was again very decent. Between
laughter she can suddenly cry. "She would not marry Doctor M.
(former asylum physician)." After seven months in a rest resort she
was discharged, returned a year later for the fifth time with rigid
euphoria from which she soon calmed down. She has now sat about
for years inactive but quiet.
Depressive Hebephrenia. Nurse. Pleasant, intelligent girl. Re-
fused several offers of marriage; she was afraid of marriage, of births.
Nevertheless she blames her sister because of the hitter's warnings
for the cause of the failure of a certain relationship with a man. From
her twenty-ninth to her thirty-second 3'ear she was with us as a con-
scientioue nurse. Because of physical diseases she resigned and then
held various other positions. After a while she became tired, sensi-
tive, considered herself annoyed, in part rightly so, because she angered
others because of her irritabihty. She felt herself getting weaker and
weaker; work became too hard for her. When she was to take over
another ward in the hospital where she worked, she became afraid
and left. She was dissatisfied with the reference. She planned suicide
and consequently at thirty-seven was brought to us. Here she was
more or less depressed, had entertained mild ideas of reference. Now
and then she heard some voices, was at times bothered by memories
of her youth that crowded up in her. Then she was better; she was
afraid to leave the hospital; but after thirteen months she could be
discharged to take a position. She did her work well but soon found
it too hard, took several other positions, but could make up her mind
with difficulty and after eight months had to be brought back to the
clinic. She had lost much of her energy, had a certain insight into
her disease but only at times, spent much time in bed, worked little.
Work was too much of a strain for her; at times she spoke listlessly
of going away, but was always afraid when it came to the point, was
very sensitive even toward her relatives. After about a year she was
again discharged. Since then she has been in different positions but
has been in difficulties (four years).
Hebephrenia with Transition Paranoid Form. As a child
to the
somewhat apathetic. While in a foreign board-
Lost her parents early.
ing school a "nervous disease" appeared for which she was treated
unsuccessfully for a year, with persuasion. But she was seized with a
morbid feeling for the physician and had to be taken away from him
almost with force. She came to another physician's house, then to a
relative where she busied herself with house-work. At twenty-four
she went to England to board where she had several sentimental and
pious friendships. "For convalescence and also for work" she returned
to Switzerland at thirty-three, then went to a relative in America, let
a friend of his cheat her of her money, but returned in time to Switzer-
land, because she had lung trouble. Later she was operated for an
intestinal growth. In the hospital she was depressed and cut her
throat with a pen-knife, whereupon at thirty-five she was admitted
to the clinic. Here she was fearful, liked to stand at the door in her
shirt, called to everybody that passed that she had to go on the street
in her shirt. Finally she did not want to put anything on, tore her
shirts because they were too beautiful. She had to be tube fed, and
slept very little. When the door opened, she always thought now
some one was coming to torture her to death. She did not want to
urinate because she was being watched through the windows. Active
auditory and somatic hallucinations concerning which, however, she
spoke little. After four months she was somewhat quieter. But the
voices forbade her to speak loudly. She always was glad to return
from visiting relatives. The voices tell her they are not the right
relatives. She has to be assured that she has not a cat and a dog in
her bowels. During sleep she is transported to many places, once
with the room and all to a river, then again to a place where there is
snow. "The furniture has wilted because of the rays from her green
eyes." After a while the sad mood changes to a mildly manic which
in the course of a year makes way for a very apathetic one, but always
with brief fluctuations upward and downward. She is to be destroyed
purposely, she hears many voices, mistakes people, is afraid to go into
the open where there are people who shoot her; the physicians do
dreadful things to her body. Nevertheless with mild protesting she
is very pleasant, as far as her indifference permits. The friend from
America, in the form of a nurse, has sneaked up to her. She is given
poison and disagreeable things to eat. Her uncle was in a tree oppo-
site her window and wanted to shoot her ; but an angel protected her.
She is The nurses
being hypnotized, cats' eyes have been put into her.
talk about ber. Her passport has been forged. An illegitimate child
has been put over on her. Men, dressed as nurses, come in, bind her,
hit her on the head, hypnotize her, pour poison into her eyes, throw
stones at her. Aside from this she is very quiet, busies herself with
womanly tasks and copying.
Hebephrenia with Fatal Results. Intelligent business woman. At
flineteen a melancholic depression. Afterwards a good worker but
never very energetic. At thirty-eight work became too much for her.
Attacks of insomnia, anxiety, and reticence; when making purchases
she often could not find words at all, or could not speak on other occa-
sions. Then showed ideas of fearful observation and reference. A
stay in a private institution did not help, nor did her leaving it help
any. After two years the patient was brought to the clinic, where
within a few days she became euphoric. At the same time she was
indifferent, untidy, concealed books, played a few bars from sheets of
music and then threw them on the floor, etc. Nevertheless she main-
tained herself in the bestward where she worked a little without doing
much. Once she wrote home a verbigerating letter. An attempt to
take her to her family failed since she did not work at all and was very
untidy, did not even dress herself and did not comb her hair. Brought
back to the asylum she remained mildly euphoric but always worked
less, became more and more untidy, kneeled or lay down on the floor
when she thought She endeavored to give her laziness
herself alone.
an Later she was occasionally unclean, deposited
aristocratic tone.
her feces in unsuitable places. After a stay of six years in all, being
forty-five, she rather suddenly became anxiously depressed with a
desire to go away, to hold on to things, tomake a noise in long and
endlessly repeated sentences; with this there was sexual excitation.
In the course of two months there was a return to the status quo ante.
But soon she became sick again with fever without any physical signs.
She had a temperature of 104 F., which subsided after five days and
gave way to subnormal temperatures (down to 96.8 F.) Her strength
failed rapidly. To be sure her pulse even shortly before her death
was noticeably strong, not rapid but often irregular. Rigidness of
the neck (or negativism) ;
patella reflex very changeable, at times
diminished, at times exaggerated. No Babinski. Several times
analgesia. Rapidly spreading decubitus in spite of all preventive
measures. Coma. Death after a duration of twelve days of the entire
acute stage. In the brain, nothing was found maroscopically; micro-
scopically marked increase of the glia in the cerebrum in all parts
without any changes in the ganglion cells.
Schizophrenic Hypochondria. Very able farmer's girl, intellectually
and physically above the average for obvious reasons she did not have
;
much schooling. Father and grandfather had suffered for years with
"stomach cramps." Patient was a very good silk weaver; she had
the more difiicult work as well as the accounting; she lived with her
brother. She positively refused offers of marriage; "she could not'

make up her mind," "was afraid of marriage." A few intimate friend-
ships with girls; even in the asylum she composed a poem of "friend-
ship" that betrayed strong homosexual components. When she was
forty-seven, her brother died. Now she was "overworked," and had
stomach trouble, soon had to give up altogether. She went from one
doctor to another, obtained the most different diagnoses, stomach and
bowel weakness, decay in the stomach, membranous colitis, multiple
gall stones, cirrhosis of the liver, floating kidney, later also hysteria.
The medicines that she took "were poison to her" and with electrical
treatment, massage, persuasion and other nice things, within a few
years wasted her fortune of 10,000 francs so that she became a public
charge. At last she came to us from another asylum where they could
not get along with her. She was fifty-four years old, physically perfect
and strong. She complained about sluggishness of the bowels, blocking
of all secretions, enlarged womb, which presses on the bowels, the
contents of which were rotting; terrible pains, valvular trouble of the
heart, etc., etc. Treatment by ignoring or diverting her brought it
about in the six years that she was with us that she again worked daily
and usually resigned herself not to ask for treatment. Nevertheless
with the reservation that we did not understand her serious malady.
If one speaks to her about her disease, she scolds about her suffering
and the treatment. But within a few seconds she can be made erotically
friendly. For instance, she lies there half dead in pain; one asks her
to dance and she joins in until she is dizzy. While talking about
the disease she sometimes has a pronounced paranoid look and always
a strong Veraguth sign; both disappear immediately when she is
diverted. Once I let myself be persuaded to give her a laxative
because she maintained she never had a movement. She persisted
in maintaining this in spite of several stools daily ; she got a little thin
and never complained as much as at this time. She did not return
from a walk, and has since remained with relatives (two years).
She masturbated very much. Distinguished from hysteria: Complete
indifference to everything that does not belong to her disease, and to
the disease also if she is not given the opportunity to talk about it.
The only rapport with her is concerning the disease and then it is
of a simple erotic nature which is in marked contrast with her intelli-

gence in other respects and her good manners. In the ward she lived
on entirely dereistically without making herself noticeable, associating
altogether with the other schizophrenics. If she complained of the
nurses, she did not make a scene. Sometimes she plainly showed
rigid affects. The hypochondrical delusions were too senseless for a
hysteria. Absolute inability to discuss or be influenced in regard to
her disease (the slight improvement was only gained by indirect

means). Psychically, her libido remained attached to her brother,
to whom she usually associates, as soon as she talks of marriage.
In contrast with her usual indifference toward everj^thing that does
not concern her disease, she can cry when she remembers him. When
he died, she lost all emotional connection ; work also became too much
for her; "over-exertion" with subjective troubles of the stomach and
bowels. Some chance remarks of the patient indicate almost certainly
that the imagined uterus enlargement sprang from the desire for
children and that the bowels, as is frequently the case, represent the
uterus.
Hebephrenia with Alcoholism. Baker and formerly a saloon keeper.
Medium intelligence. Always given to rage, is coarse. At twenty-six
he had his own business, which gradually declined. At thirty-eight he
heard voices, became anxious, barricaded the doors; at night looked
for man that pursued his wife found her bed in disorder, suddenly saw-
;
heads. Attempted suicide for the reason that his license would be
withdrawn, because many unclean things walked in his saloon. For
this reason he was brought to the hospital; came home improved,
drank nothing for a while, worked well but reproached his wife for
having been interned. Then he began to drink again, again had the
jealousy ideas, but only when he was drunk. Worked irregularly.
Because of violence, he was again brought to the clinic. He could not
understand a fable clearly, had all sorts of drunkard's excuses, but
was less capable of discussion than ordinary drunkards, and sometimes
made very peculiar movements. Affectivity was at first still labile:
tears in his eyes over the interning, then again rigid and indifferent.
Now and then peculiar movements. After seven days he went to
another hospital with the diagnosis of hebephrenia and alcoholism.
From there he was discharged after twelve weeks. This time, too, at
first everything went well for a short time while he abstained from
alcohol, then he continually became worse. Jealousy delusions and acts
directed against the wife. He had to
give up his business because, while
drunk, he threw bread and other things out of the window and insulted
his customers. He worked as a baker's assistant and then for weeks
not at all. Now and then it was noticed that he did not speak. The
jealousy ideas became steadily worse. In the vilest words he asked
the children about his wife's infidelity. Furthermore, he laid match
sticks together in a particular way and said mysteriously that meant
something. Because of maltreatment of the wife he was brought back
(aged forty-seven). On admission he showed complete blocking.
Later acted as formerly. After a few days he went to another hospital.
The next year he was brought in again with mutism, and com-
pressed lips. On the outside he had called attention to himself by
all sorts of senseless acts; e.g. he had stood in front of the street
car and had waved his handkerchief. Discharged again, he was

conspicuous, worked very httle, made all sorts of faces so that people
were afraid of him, beat his wife and children. Nevertheless only
after nearly five years he was returned in a state of alcoholic
and schizophrenic dementia. He was transferred to another
hospital.
4. Where only symptoms are visible, we speak of schizo-
the basic
phrenia simplex primary dementia of earlier authors). It is
(the
usually a case of a dementia in the sense of schizophrenia that increases
gradually in the course of decades. The anamnesis invariably indi-
cates that the disease has been mistaken for many years; it was a
latent schizophrenia. But since this form also, like every other, need
not progress to the point of recognizable dementia, there are undoubt-
edly latent schizophrenias, too, that never become manifest. One not
rarely meets with it in relatives of the manifestly diseased, or in visits

with patients who come because of some "nervous" trouble.
Schizophrenia Simplex. Teacher. always somewhat
Intelligent but
peculiar, retiring, had various hobbies. At school in the course of
time matters became worse. His discipline relaxed. But not until
he was fifty was it pointed out to him that matters could not go on
in that way. Instead orf seeing it in this way, he demanded several
increases in salary from the authorities. At last he had to resign
and then entered into incessant litigations "about his rights"; the
authorities had to get him a good position. He was completely incap-
able of seeing the material and formal impossibility of this fulfillment.
At last he threatened to thrash the authorities, and was sent to the
clinic as dangerous. Here he permitted himself to be somewhat calmed
externally, and after eight months could again be discharged. On the
outside he has been getting along for nearly twenty years, by occupying
himself with subordinate farm work.
Kraepelin recently formulated a somewhat more exhaustive
grouping:
1.Dementia simplex, corresponding to the hitherto established
group. 2. Foolish dementia, corresponding generally to the Hebe-
phrenia of Hecker and well designated by "the name. 3. Simple depres-

sive or stuporous dementia often has a preliminary stage lasting for
years in which the patients retire, become peculiar, and brood. Only
in about twenty percent does a milder schizophrenic depression with
ideas of sin and persecution and often too with catatonic symptoms
break out without such an introduction. A fairly large number of
the patients afterwards merge into a tolerable condition "without severe
dementia but the attaeks may recur. The stuporous dementia includes
;
many of our catatonics with a depressive stage, but perhaps also the
Hebephrenics. 4. Depressive dementia with delusional formation have
similarsymptoms but on the average run a more chronic course, have
a somewhat worse prognosis and show the delusions more conspicu-
ously. 5. In the circular form excitations and depressions alternate;
they usually lead to severer dementia. (There is another formation
to which, perhaps, this name might better apply, since it runs its
course in evident manic and depressive attacks which are sharply dif-
ferentiated from better intervening states, or from those which, in the
beginning, are very good) 6. In the agitated form one observes con-
.
tinuous excitements with compulsive acts, senseless movements and a

general exalted mood. (This form seemed to Kraepelin the most fre-
quent with the natives of Java.) 7. Forms with periodic attacks of
confused excitation that usually begin and end very acutely, which
usually do not last long, only a few weeks, and are combined with a
marked loss of weight. Not rarely they are associated with menstrua-
tion. 8. Catatonia, including the severer cases of the disease hitherto
designated by this name by Kraepelin. 9. The paranoid forms, corre-
sponding to our paranoids and divided into dementia paranoides gravis
with a severe decay of the psychic life, disturbances of the feelings and
will, as well as loss of external bearing, and into paranoid or hallucina-
tory feeble-mindedness, in which the hallucinations are in the fore-
ground, but in which the fundamental personality has suffered less
(dementia paranoides mitis) . 10. As the tenth form, speech confusion

(schizophasia) should be distinguished, running its course with very
severe speech disturbance up to a complete word salad, but with rela-
tively slight impairment of the other faculties, so that the patients are
still fairly capable of work, at least within the asylums.
E. The Course
It is impossible to describe all the various courses of schizophrenia.
Pretty nearly all imaginable combinations of courses may occur except
the recession of a severe dementia. Nevertheless two types recur with
special frequency; the course which is chronic from beginning to end,
that requires many years for development, and the manifest type,
beginning with an acute onset, and leaving behind secondary demented
or paranoid states. But the acute syndrome need not leave behind an
increase of the dementia, and on the other hand, the dementia as
well as the formation of delusions may progress after, as well as
between, the acute attacks. Forms taking an entirely chronic course
belong especially to the simple schizophrenia and to certain catatonic
ways of manifestation, also to the typical paranoid forms.
In every course exacerbations may appear at any time, but after
the disease has lasted from two to three decades they are pretty rare.
Complete arrests of the diseases are not frequent in asylum patients.
In the course of decades an increase of the dementia can usually be
noted. Among the more mildly afflicted, who maintain themselves
outside of asylums, some seem not to go beyond a certain stage of
the disease.
Improvements also may occur at every stage; but they relate
primarily, to the accessory symptoms. Schizophrenic dementia itself
no longer actually But to be sure all acute syndromes show

regresses.
a tendency to disappear, and chronic hallucinations and delusions
may also regress, though much more rarely. Psychoses which, from
the beginning, run a course unth a picture of a chronic catatonia, are
quite hopeless. Excited patients calm down as a rule in the course of
years, in part because inwardly and outwardly they become used to

the hallucinations and to the dissociation, or also because the sense
deceptions decline in numbers and intensity.
The sudden and transient akalmias in the severe acute as well as
in the chronic conditions are noteworthy. A highly excited, especially
may, with or without external cause, appear entirely
a confused, patient
normal from one minute to the next, only to fall back after hours or
days into the previous condition.
The qualitative course is somewhat more regular; the majority of
cases from the beginning to the end remain within their category,
even though a change from catatonic to paranoid forms and in every
other direction is more frequent than in the various forms of paresis.
The beginning of schizophrenia is in reality usually furtive. Even
though the disease often becomes obvious to the relatives first through
an acute attack, a good anamnesis usually reveals certain previous
changes of character, or other schizophrenic signs. Whether the in-
clination to retirement, often noticeable even in childhood,combined
with a certain degree of an expression of a disposition,
irritability, is
or the actual beginning of the disease, cannot be decided. In many
cases the disease itself makes itself felt by a gradual decline of acquired
skill and of capacity to work; in others, neurasthenic, hysteric, or com-
pulsive neurotic symptoms are for years mistaken for the disease and
treated unsuccessfully. Anomalies of character and single immediate
acts are much more conspicuous.
In a small number (under one percent) the outcome is death from
cerebral inflammation or from the cessation of metabolism. Other
patients die from the indirect consequences of schizophrenia, from
injuries that are intended, or result from carelessness, and suicide.
Usually phthisis is alsomentioned but with satisfactory hygienic
measures it is no more to be feared in asylums than in those mentally
sound.
A small part is "cured" to such extent that only a very careful
inspection shows any signs of the disease; one may observe a certain
irritability, some remnants of the delusions, some peculiarities, etc.
Nevertheless there are a great many "social cures." Under the condi-
tions in our hospital one can figure that only about one third of the
more severely demented and more than half of the others remain
fairly capable of work for a considerable time, or permanently. Cata-
tonia, especially in men, has a somewhat poorer prognosis than the
other forms; pupillary symptoms also seem to occur chiefly in the
more serious brain affections; and whenever it is ascertained that the
patient showed previously an "abnormal" character the prognosis is
less favorable. The twilight states regress the more completely, the
purer they are. But aside from what was said we unfortunately have
no basis at the beginning of the disease for the prognosis of its duration.
Terminations according to Kraepelin
Among the terminations Kraepelin mentions the following forms,

which naturally are not clearly defined from one another.
1. In simple feeble-mindedness the defects above all influence the
affectivity, whereby a certain ability to work is retained. 2. Hallu-
cinatory feeble-mindedness is similar, but is permanently accompanied

by individual sense deceptions the nature of which the patients recog-
nize more or less, so that their external conduct may, in the main,
still be orderly. 3. The dementia paranoides mitis is characterized by
delusions and hallucinations, which, as distinguished from the previous

group, are very numerous. 4. The drivelling dementia shows a severer
unsteadiness of the train of thought with senseless delusions and sense-
less speech. 5. The dull dementia approaches the quiet of the grave,
even though individual patients perform simple tasks, and occasionally

excitations and more positive symptoms like stereotypisms, etc., are
hardly ever entirely absent. 6. The silly dementia expresses itself
in greater activity with a usually cheerful mood and silly actions.
7. The dementia with mannerisms is similar; here, however, peculiar
deflections of volitional acts (like hopping about on one leg, stereo-

type positions, etc.) stand in the foreground of the morbid picture.
8. Negativistic dementia is characterized by the strength of the im-
pulsive resistances.
F. What Is Included under the Term

Under schizophrenia are included many atypical melancholias and
manias of other schools (especially nearly all "hysterical" melancholias
and manias), most hallucinatory confusions, much that is elsewhere
called amentia (our idea of amentia is much narrower), a part of the
forms consigned to delirium acutum, motility psychoses of Wernicke,
primary and secondary dementias without special names, most of the
paranoias of the other schools, especially all hysterically crazy, nearly
all incurable "hypochondriacs," some "nervous people" and compulsive
and impulsive patients. The diseases especially distinguished as
juvenile and masturbatory forms all belong here, also a large part of
the puberty psychoses, and the degeneration psychoses of Magnans.
Many prison psychoses and the Ganser twilight states are acute
syndromes based on a chronic schizophrenia. If we still come across
reactive psychoses included under this head, then it is due to defective

diagnoses, not to the classification of a system.
Latent schizophrenias are very common under all conditions so that
the "disease" schizophrenia has to be a much more extensive term
than the pronounced psychosis of the same name. This is important
for studies of heredity. At what stage of the anomaly any one should
be designated as only a "schizoid" psychopathic, or as a schizophrenic
mentally diseased, cannot at all be decided as yet. At all events, the
name latent schizophrenia will always make one think of a morbid
psychopathic state, in which the schizoid peculiarities are within
normal limits. Social uselessness, catatonic symptoms, hallucinations,
delusions make certain the practic?J diagnosis of the acute mental
disease.
Paraphrenias. Kraepelin attempted to separate from the paranoid
forms of schizophrenia, as a special morbid group, those in whom
the personality was better retained, and whose feelings, will, and
the external behavior are directly slightly changed; the incorrect
actions are determined by delusions. In the paraphrenia systematica
more or less connected delusions are conspicuous; they show, in the
first place, the character of persecution, but later, beginning with a
definite period, they become associated with grandiose ideas. Para-

phrenia expansiva presents a light manic lasting mood, and, corre-
sponding with it, luxurious ideas of grandeur from the very beginning.
In paraphrenia confabulatoria the delusions appear as memory decep-
tions. The paraphrenia phantastica (paranoid dementia in the old
narrow sense) ^^ frequently develops even in a few months into quite
a stable picture with a number of alternating senseless ideas of grandeur
and persecution, with an enormous number of somatic hallucinations,
often quite senseless speech, but a less conspicuous outward behavior,
and under care a more or less continued productive capacity. A
diagnostic differentiation of the paraphrenias from the other acute or
chronic mild paranoid forms was never possible. Moreover our investi-
gations, as well as the course and heredity, show the definite rela-
tionship of most, if not all these cases, to the schizophrenias.^
G. Combination of Schizophrenia with Other Diseases

Schizophrenia may be combined with other psychoses; it may un-
doubtedly originate on top of oligophrenias (Propfschizophrenia),^^
""See p. 413.
*'
Conip. Schizophrenia, p. 177.
" Moreover, manj' Propfschizophrenias represent probably a distinct disease.
At all events intercourse with most of these patients is maintained by way of
the affects.
and may be followed by senile psychoses. Occasionally also a paresis,
more frequently alcoholism, eventually with delirium tremens or
hallucinosis, complicate the picture. There is probably also a mixture
of manic-depressive insanity, and of epilepsy with schizophrenia. The
associations of these two diseases with dementia prsecox are undoubt-
edly multiform and not at all clear, no more than the delimitation of
the combined from the simple forms with only apparent mixture
symptoms.
H. Diagnosis
The diagnosis of schizophrenia in the ordinary cases is Very easy.
The peculiar, moody, abrupt, and scanty affective rapport often points
to the disease at the first glance; furthermore, the inability to discuss
matters that deal with subjects that the patient is otherwise con-
versant with. Also many accessory symptoms like the above described
delusions, the hallucinations characteristic in their way, especially the
physical sensations, pronounced catatonic symptoms, all make possible
a quick recognition. examination does not yield definite indica-
If the
tions one should carefully ask whether there are people who annoy
the patient, whether there is anybody in his neighborhood who is
hostile to him. Often a secretive persecutory mania will then come
to light. But nowhere as much as in schizophrenia are all individual
symptoms evaluated in terms of their entire psychic environment.
to be
In case of cloudiness of consciousness the identical manifestations are
not nearly so valuable as evidence as in the case of apparent clearness.
Catalepsy also occurs in epilepsy, in hysteria, then again in cerebral
diseases, and as a concomitant manifestation of bodily diseases, e.g.
uremia in children. In negativism the impulsive variety has to be
differentiated from those forms of rejection based on other reasons.
In any schizoid character any other psychoses can easily bring to
light a few schizophrenic symptoms.^ Beginners are then easily in-
clined to see only the schizophrenia. Of the physical symptoms only
the lack of psychical pupillary reaction has a more definite significance.
One may never directly exclude a schizophrenia.
Only prolonged observation will often guard against confusing
schizophrenia with manic-depressive insanity. All manic-depressive
symptoms may appear in schizophrenia but not the specific schizo-
phrenia symptoms in the former disease. The simultaneous existence
of grandiose ideas and depressive delusions indicates schizophrenia.
From paresis and dementia senilis it is definitely differentiated by the
absence of the signs of the organic psychoses (eventually by the exam-
Comp. p. 177.
ination of the cerebro-spinal fluid). Coarse cerebral lesions may

sometimes simulate a schizophrenic picture for a considerable time.
A stupor may occur in an imbecile as a result of an unusual situation,
e.g. in case of a judicial examination. From epilepsy it is differentiated
especially by the striking schizophrenic anomalies of the affects, then
on the other hand by the absence of the epileptic hesitating mental
trend, the epileptic speech, and by the adhesiveness of the feelings.
In the anamnesis of epilepsy the picture is usually dominated by the
attacks, in the dementia prsecox, even when attacks are present, it
is dominated by the psychic disturbances. Epileptic catalepsy usually

persists only a short time, e.g. a fractional part of an hour, never a
month, as the schizophrenic. In epileptic cloudings of consciousness,
especially when brain lesions are the basis of the disease, paresthesias
sometimes occur which are elaborated in a dream-like manner and
may simulate schizophrenic hallucinations of the organs. The various
alcoholic psychoses not rarely originate on a schizophrenia which they
then complicate. The differentiation from hysteria and neurasthenia,
which at the beginning of the disease involves many pitfalls, is nega-
tive, as in manic-depressive insanity. As psychogenic symptoms occur
in all three diseases, we presuppose schizophrenia when specific symp-
toms of this disease are demonstrated; we presuppose hysteria and
neurasthenia when a minute examination has brought to light hysterical
or neurasthenic but no schizophrenic symptoms. Dementia, disturbance
of ideas, auditory hallucinations and permanent delusions with
unclouded consciousness exclude the neurosis.^
Especially difficult is the delimitation of reactive syndromes, or
logical peculiarities in psychopaths. As yet we have no standard to
tell us how pronounced the sj^mptoms must be to enable us to assume,
or exclude, a schizophrenic process. In these cases one will assume
schizophrenia only when more definite signs of it are present, but
.
will be careful not to want "to exclude" it. Young people are nearly
always schizophrenic who want to become something out of the
ordinary just at the time that they are really failing, and who then
believe that by particular tricks (thinking out something to the end,
etc.) they can free themselves from the situation and then neglect the
essential thing in favor of the means.
Oligophrenics who get symptoms that are of a paranoid nature or
similar to those of catatonia are sometimes impossible to differentiate,
because just here the diagnostic standard for such manifestations and
even the limitation in principle of oligophrenia ^^ are still uncertaia
**
Compare the differential diagnosis in chapter on hj^steria.
*
Comp. paranoia, limitation.
I. Prognosis
The course of the disease runs in the direction of the described

dementias. The special directional prognosis is decided with some
probabiUty by the assignment of a case to one of the sub-groups.
The extent prognosis is much more uncertain. Many cases after the
first shift, under certain conditions even show such a slight
later,
defect that they may be considered practically cured; others become

demented quickly and to a high degree. To the latter belong with
certainty all chronically beginning catatonias, probably also the rarer
cases mental confusion in the sense previously explained. All
of
acute syndromes may regress to the former state. Very severe acute
conditions with profound disturbances of consciousness are, therefore,
not in themselves hopeless. But the cardinal symptoms regress very
little, and of these, the disturbances of association least of all. In
acute conditions the most important consideration is to determine
how far the actual schizophrenic process has progressed. The more
the schizophrenic picture of associative and affective disturbance pro-
trudes from behind the transient acute symptoms, moods, stupor,
and hallucinations, the worse the prognosis the more a picture resem-
;
bles a pure mania or melancholia, the better the prognosis. Naturally

this does not make it very good because this observation only deter-
mines that as yet no dementia has set in, but not that it cannot set in.
The anamnesis also often gives important basic points. Good remis-
sions after earlier shifts warrant, with considerable probability, the
expectation of another extensive improvement. On the other hand,
the confirmation of an extensive dementia already existing before the
actual shift excludes any considerable improvement, because improve-
ments over the earlier conditions are only rarely found after an acute
onset; exacerbations of the various grades are very common.
A favorable sign, especially plain in women, is the retention of
decency in acute conditions, while a visible loss of the feeling of
decency in a clear sensorium and otherwise orderly conduct is a sign
of poor prospects. But the reverse inference would not be at all
justified, namely, that absence of a feeling of decency in acute condi-
tions indicates abad outcome, and that the presence of decency in a
state of mental clearness indicates a good one.
Actual chronic conditions are capable of little improvement; only
we do not always know what is chronic. There are patients who for
many years are at the same stage of excitement but still give the
impression, more or less, of being acute and are then again surprisingly
capable of improvements; after ten or twenty years in rarer cases,
apparently entirely unsocial patients may be discharged as again

capable of work. Moreover the increase of dementia is often to be
taken externally as an improvement; the patients gradually become
more indifferent toward their delusions and voices and consequently
quieter; under certain conditions they even become more capable of
work. In many cases the hallucinations decline after a while to the
point of disappearance.
The tendency to relapses is hardly to be estimated. The longer
an interval lasts, the less a new shift is to be feared. After a standstill
of two decades there may still be a quietly progressing decrease of
ability to work but only rarely new attacks. The climacterium, preg-
nancies, and especially the puerperium, present a certain danger to
women.
K. Causes
Great importance is undoubtedly to be attached to hereditary bur-
dening. Among the direct ancestors of the patients, psychoses, espe-
cially schizophrenia, are much more numerous than with the healthy.
Most frequently one find in families schizoid characters, people who
are shut-in, suspicious, incapable of discussion, people com- who are
fortably dull and at the same time sensitive, people a narrow who in
manner pursue vague purposes, improvers of the universe, etc. Natu-
rally nervous diseases also occur in the families of schizophrenics,
often because many milder schizophrenics are so called. Some family
relationships with a certain kind of epilepsy, that as yet cannot be
characterized more definitely, seem to be present. Besides there are
schizophrenias where an hereditary disposition is not to be found in
spite of exact information concerning the family.
In probably three fourths of the cases the personal disposition
already expresses itself during youth in an dereistic character inclined
to seclusion, then in other peculiarities and deviations from normal

thinking. A
small percent of the pronounced diseases themselves go
back into childhood. Most of them become manifest from puberty
up to the twenty-fifth year; from thirty on, the morbidity sinks rapidly
to rise again, inwomen, to a low second peak at the time of the cli-
macterium. Only the chronic paranoid forms show a preference for
breaking out rather late, especially around the fourth decade.
Among the external conditions pregnancy and, more readily, con-
finement at times precipitate attacks of schizophrenia, also perhaps
acute infections, but not frequently, then any psychic factor, especially
an unfortunate love-life. But we must assume that the disease is not
engendered by such conditions but only made manifest. Onanism
and over-work are both blamed as causes, absolutely without any-
Neither the grippe nor the war have added to the
justifiable reasons.
existence of schizophrenia.
L. Frequency and Prevalence

Aside from the oligophrenias and alcoholism, schizophrenia is the
most common mental disease. In our asylums it is found in 23 percent
of the men and 39 percent of the women and the difference in the
relative numbers is due almost entirely to the excess of paretics and
alcoholics among the men. As the schizophrenics are at the same
time the incurable and the long-lived patients, they may constitute
three fourths of all the inmates in any asylum that does not admit
many cases of idiocy.
The disease occurs in all races and in every stage of culture. But
it seems that among primitive people it assumes less frequently the
character of catatonia.
M. Anatomy and Pathology

We do not know as yet on what the pathologic process is based.
In acute stages various kinds of changes in the ganglion cells are found.
In old cases the brain mass is reduced a little; many ganglion cells,
especially in the second and third layer, are changed in various ways;
sometimes the fibrils of the cells and the axis-cylinder look diseased.
The glia is regularly involved: various changes of its cell varieties,
increase of the small cells; there is a deposit of pigment and other

catabolic materials, increase of the finer glia fibres and other things
besides. The findings cannot as yet be lined up together nor interpreted
as to their causes and effects.
Naturally one thinks first of toxic disturbances, especially of the
influences of the sex organs and the thyroid also. With the Abder-
halden reaction it was supposed that signs of the reduction of these
two organs were pretty regularly found, naturally with the reduction
of other organs, especially of the brain and then the suprarenals.
The supposition of an (hereditary) schizophrenic predisposition,
which at present is being considered most, meets with many difficulties.
Our total knowledge would be completely comprehensible if it were a
case of a chronic infection or intoxication by means of a generally
distributed agency or of something teratological.
In certain acute conditions the morbid picture is evidently con-
ditioned chiefly by the anatomic or toxic processes, in the manner of
the deliria in meningitis, fever, or intoxications. Also the rarer, gen-
eral or localized, paralytic symptoms and the manifestations of brain
pressure, originate in an organic process which is indicated in the more

chronic course by only a few symptoms like tremors, pupillary disturb-
ances, and irregularities of metabolism. In other respects the process
seems to set free some associational weakness,"^ which, however, in
its results may from one moment to another from zero to
fluctuate
maximum; and hence already shows the influence of some psychic
factor; furthermore the schizophrenic associations have not as yet
been differentiated from the functional changes of the mental trend
in the dream and in distracted attention. The remaining symptoms
of schizophrenia are secondary. ^^ The content of the hallucinations
and delusions is conditioned katathymically by the complexes; un-
pleasant complexes are repressed, as in normal people, into the uncon-
scious and from there cause delusions and sense deceptions. Affective
rigidity is also seen under such conditions in normal people, and all
other affective disturbances occurring in schizophrenics are also noticed
especially in the dreams of normal people.
N. Treatment
Most all, or at any rate
schizophrenics are not to be treated at
outside of asylums. They belong
asylums only when there are
in
special indications, which to be sure appear frequently, e.g, in acute
attacks, because of disturbing conduct, violence, danger of suicide,
and then especially temporarily for purposes of training. They should
be discharged as soon as possible, because later they are gotten rid
of much less easily; because not only the patients but the relatives
perhaps more adapt themselves too quickly to the sequestration.
still
The loss of affective rapport makes itself felt in this respect also.
Expensive treatments, that are of no use anyway, should be cautioned
against, above everything. Moreover the economic and moral interests
of the healthy members of the family should not be sacrificed for a
hopeless treatment. On the other hand, the supreme remedy which in
the majority of cases still accomplishes very much and sometimes
everything that can be desired is training for work under conditions
that are as normal as possible. In seriously affected patients one
must not be afraid to prescribe such unremunerative work as cutting
wood, carding wool, making boxes, copying any sort of simple work.
It is self-evident that psychical obstacles to improvement, as irri-
tation by impatient treatment, arousing jealousy b}^ having them live
with a happily married member of the family, etc., are to be avoided.
In addition the following details should be considered. For young
"Bleuler, Storung der Associationsspannung. îtschr. f. Psychiatrie, 74, S. 1.
See p. 55.
schizophrenics capable of work simple vocations should be selected
that lead to and practical activity, and not to theory and dereism.
life
Schizophrenic whims for some calling or activity should not be mis-

taken for special qualifications. Sometimes a quiet discussion of the
frequent conflicts concerning onanism may contribute to produce calm
and probably also in the future, to the avoidance of severe pathogenic
complexes.
When the sensitive spots of the disease have been discovered, not
only can the physician more easily exert a calming influence, but those
about the patient can avoid many exciting influences (conversations
about the sister's marriage, visit of a particular man whom the patient
loved, etc.).
After the outbreak of the disease those about the patient are to
be informed that the delusions and Sense deceptions, as far as they
do not lead to unpleasant actions, are to be taken quietly and without
discussion as merely morbid manifestations. Some of the patient's
physical complaints are of a purely psychogenetic nature and are to
be treated by suggestion; others, like some headaches, sleeplessness,
accumulated pollutions, probably depend more directly on the morbid
process and may be treated with medicines, as long as the patient is
not habituated to drugs. Bromide will often help to remove the

state of general nervous excitability, even if not the real excitement.
If after the decline of an acute shift the patients continue to act sense-
lessly, and especially if their nutrition becomes reduced so as to excite
apprehension, an 8 to 12 days Somnifen half fileep sometimes produces
excellent results. To avoid any unpleasant initial manifestations it is
best to begin with an injection of Hyoscine 0.001, with Morphine 0.01.

When the patient is narcotized, that is, about half an hour later, the
patient is given one ampule of Somnifen in both left and right arms,
injecting it deeply under the skin or into the muscle. After 6 to 8
hours another ampule, and later according to need. Sleep is maintained
so deeply that the patient, left to himself, is drowsy or asleep, but
is either spontaneously or through instigation sufficiently aroused to
take nourishment, to attend to his wants, and especially for psychic
treatment. The latter is most important; one can get the impression
that in his helplessness the patient has the need to appeal to some
one; negativism and refusal of nourishment can thus be made to
disappear or can be markedly weakened. In some cases the remedy
seems to bring about directly acute hallucinatory shifts, which have
not yet been thoroughly described; here sleep will have to be main-
tained to a deeper degree. Poor physical condition seems to be no
contraindication; the patients usually gain in weight during this
treatment. When a shift of the disease has run its course and the
patient is nevertheless not freed from delusions or impulsive acts or
from his fear of life and work, a change of residence often has a good
but not to a sanitarium where one gets accustomed to laziness.
effect,
Even mild cases should not be left entirely to themselves. They need
some one who busies himself with them in a tactful way without
irritatingthem, who watches them unobtrusively, gives them support,
and trains them as much as is necessary, and as much more as is
possible. In more serious cases the tendency to become automatic
can often be used and the patients held at least externally to an orderly
existence if not at useful work. With increasing dementia, more and
more simple kinds of work have to be found.
There are cases where abortion may be resorted to, followed under
certain conditions even by sterilization, for which, however, there must
be such very definite indications, as visible aggravation through
pregnancy, uncontrollable sexual inclinations, etc. I never saw any
good results but sometimes bad ones from the persistently proposed
castration.
X. EPILEPSY
In a number of diseases that run their course with psychical symp-
toms the epileptiform attack is the most striking manifestation; we
call them the epilepsies. Among them a fairly well characterized group
includes about three fourths. of the cases; the others are insuflficiently
known and were more plainly differentiated first by an anatom-
really
ical study by Alzheimer. ^^ The main group, which is the only one
that we can give attention to here, is called genuine epilepsy, a name
that should really include the other forms too and distinguish all of
them together from "symptomatic epilepsy," or the epileptiform attacks
in other diseases. Such attacks may occur in all grain diseases (e.g.
tumors, scleroses, paresis, arteriosclerotic insanity, presbyophrenia,

and schizophrenia), as well as in toxic conditions, e.g. through alcohol,
lead, ergotin, and in eclampsia and uremia. Genuine epilepsy is
characterized not only by the chronically repeated epileptiform attacks,
but it also develops a considerable number of psychic symptoms
peculiar to it. Furthermore it frequently shows "abortive" or other
variously formed attacks, from which the disease may be diagnosed
just as clearly as from those attacks designated as epileptiform. The
**Die Gruppierung der Epilepsie. Bericht der Jahresversammlung des
Deutschen Vereins fiir Psj^chiatrie 26/28 April 1907. Allg. Ztschr. f. Psychiatrie,
Bd. 64, S. 418-
latter, may altogether be in the back-
considered as "typical" attacks,
ground or may
be totally absent without making the diagnosis impos-
sible for that reason. Nearly all cases of genuine epilepsy also show
a common anatomical finding. Nevertheless the differentiation from
other forms of epilepsy is not yet sharply defined, and it is easily
possible that the group thus delimited will also, on closer examination,
be separated into subdivisions.
In cases in which the symptoms of epilepsy and schizophrenia are
mingled clinically, Tramer also found anatomical signs of both diseases.
What is typical in the attacks designated as epileptiform is the
sudden, often actually "lightning-like" onset of a convulsion of the
entire muscular system, which has at first a tonic, and then a clonic
character; it lasts not more than a few minutes,^* and is associated
with a profound disturbance of consciousness, which leaves the im-
pression of a complete loss of consciousness.
The attack is often preceded by prodromata which last a few
hours, more rarely days; most frequently they are represented by
"moods," but also by any ill feeling, more rarely hallucinations and
twilight states. In most cases these prodromata disappear in a trice
with the attack.
The attack itself is often initiated by an aura. This most fre-
quently consists of any kind of paresthesias, a pain, a feeling of cold,
or being blown at (hence the name) which, however,
, is not so frequent;
"a wheel is turning in the stomach"; then it may be initiated by real
hallucinations, especially of sight and also, noticeably often, by those
of taste. The visions often show the tendency to approach the patient
and get larger and larger; the moment they touch his breast, conscious-
ness disappears. In the rare "reflex epilepsy," whose attacks are set
free by the irritation of a scar or some other pathological focus, the
aura may begin as a sensation in the particular part of the body. In
some cases complicated scenes are hallucinated. The psychic aura may
also consist of sudden moods or subjectively felt disturbances of
thought. There is beside a motor aura, consisting of all sorts of clonic
and tonic, usually circumscribed, convulsions, lightning-like twitches, or
complicated automatic movements, as, especially, aimless running (aura
cursoria) ; it rarely goes as far as complicated acts like undressing, etc.
As the muscles of expiration and those closing the glottis are
" Relatives often speak of attacks of longer duration. This is due primarily
to the fact that the terrible scene leaves the impression of a longer duration.
Moreover the intermingling of the two phases with the stuporous after-effect,
or the confusing of the attack with the status epilepticus, also contributes to
this idea.
stronger than their antagonists, at the beginning of the general con-

vulsion the air is usually pressed out through the closed vocal slit,
thus causing the characteristic scream. Much more rarely it is a

terrible scream of fear, belonging to the psychic, that is to say, cursative
aura. With the scream the patient usually drops like a log without
any regard for danger. An absolute immovable rigidity probably never
occurs; a more strongly contracted group of muscles overcomes the
opposing muscles and thus produces a slow movement; often one side
especially predominates, then the other. In the tonic state livor
naturally occurs, in severe cases, up to a terrifying dark blue; after
about a half a minute one sees jerks in individual muscles that spread
rapidly and go over into wild clonic convulsions. After a while one
usually notices, in the chaos of movement, a certain purposeful co-
ordination becoming visible, especially in the sense of defense. At all
events, the movements become weaker until complete quiet takes
some jerks of declining severity follow. Coordination,
place; usually
and to a certain extent the ability to move, usually return only
gradually, in the course of minutes or also after a much longer time.
Only in exceptional cases does consciousness appear suddenly or as
early as the cessation of the motor attacks; usually the thoughts are
gradually collected and with numerous fluctuations in the degree of
clearness. Orientation, at first falsified, becomes clear first in respect
to individual things, later on being spoken to, and then in other
respects. The patient does not awaken as if from nothing, but as if
he were coming out of a dream state. Sometimes circumscribed
paresthesia, and more rarely paralyses, remain for some time.
In severer attacks the salivais whipped into foam by the movements
of the tongue and also by the strong mouth-breathing that appears

after the tonic convulsions this foam is frequently colored with blood
;
because the tongue gets between the teeth. If one can examine the
pupils during the attack, at the very beginning one usually finds miosis,
but later pronounced mydriasis and rigidity, w^hich after the attack
make way with varying speed for the normal reaction. During the
attack some patients sometimes involuntarily pass urine, very rarely
feces. During the attack and usually even at the beginning of the
stage in which movements and facial expression indicate a dream
state, the patients do not react to exiêrnal stimuli; the reflexes too
disappear for a considerable time; the Babinski sign is often present.
When the post-epileptic clouded consciousness lasts for hours and
days instead of a few moments or minutes, or when noticeable actions
are committed in this state, it is considered an independent post-
epileptic tmilight state. After the clouding of consciousness but often
also immediately after the attack a stupor or actually a coma usually
appears, sometimes also flexibilitas cerea. After the awakening a feel-
ing of perfect well being is decidedly rare ; on the one hand the patient
usually feels nervous irritation, and on the other, he feels "knocked
out," even when he has not really hurt himself. The pulse often keeps
fluttering for hours. The Babinski sign may continue into the next
day.
In the same patient the various attacks may have a photographic
resemblance. In falling the patients land on the same part of the
body; the aura is as a rule of the same form; in the post-epileptic
twilight state the identical sense deceptions are perceived, and the
identical acts are performed in the same succession.
The attacks may become abortive in the most diverse ways; this
is especially true with the development of dementia when everything
as a rule becomes Furthermore the tonic or clonic states
less vigorous.
may be reduced to a mere indication; the movements may from the
beginning have the character of an action, even though it be irregular.
Mere fainting spells also may be abortive epileptic attacks. If con-
sciousness disappears for only a few seconds without the patient
falling down, and is usually accompanied by pallor, more rarely
blushing, and if it is often combined with a staring gaze, sometimes
also with some movements of the lips or tongue, one speaks of absences
or petit mal, in contrast to grand mal, or the pronounced attack. Some-
times the disease shows itself in rapidly disappearing attacks of dizzi-
ness. Besides these most frequent "attacks," there are many other
minor symptoms of the same significance that cannot all be enumerated.
In all these minor attacks there is hardly ever an absence of a dis-
turbance of consciousness, which appears suddenly without a pro-
dromal stage, partly in the form of an (apparent?) diminution of con-
sciousness, and partly in the form of twilight thinking, or in the
obtrusion of a certain thought, etc. Thus a patient suddenly gets up
from a meal and masturbates; another urinates in the ticket box.
Concerning pure hallucinatory states we get information only when
the amnesia is lacking: thus the entire surroundings suddenly disappear
for the patient, and instead he sees some rapidly moving cats.
The typical attacks at times follow one another so quickly that
the patients do not recuperate in the interval: status epilepticus. In
severer attacks of this sort the temperature then rises to unusual
height (109 F.) and the patients die in coma or from aspiration
pneumonia.
The psychical disturbances. Epileptics are as a rule psychopathic,
even before the disease has left its characteristic mark on them, A
large part of them, especially of the forms afflicted while young,

actually have brain disease or are imbeciles. But specific psychic
peculiarities are connected with epilepsy, which as a rule increase
with the duration of the disease. Ac(;ording to the degree one speaks
of an epileptic character, epileptic psychopathic constitution,""' and
in severer cases, of epileptic dementia.
The most conspicuous anomaly concerns the affectivity, which re-
acts to a morbid degree, and at the same time shows the peculiarity,
that an existing affect lasts a long time and it is difficult to divert it
by new impressions; it is not merely irritability that shows itself in
this manner but the other affects, as attachments, or joy, all take
the same course. The patients as a rule have a very decided mood,"
and the unimportant very readily takes on as strong an emotional tone
as the important. It is not true that some feelings, as, e.g. the moral
feelings, atrophy. On the other hand, there is found a disproportion-
ately strong affective coloring of conceptions that concern "righteous-
ness." An increased interest is devoted to the patient's ego. But the
egocentric trend of thought also has an associative root besides the
affective.
and most noticeable of all the mental stream,
All psychic functions,
are markedly retarded and run heavily, and if the flow of speech may
be taken as a measure, they preferably take place in a hesitating
and jerky manner. The contextual peculiarities of the mental stream
are most plainly revealed in the experimental associations where
one observes: retardation, poverty of ideas, a tendency to repetition
in form and content, to form definitions, difficulty in reacting with a
single word, frequency of egocentric references, emotional accentuation
of the preferred ideas, and the selection of reaction words that
are indicative of emotion; in this respect, there is a particular
preference for affective evaluation, as seen in the frequent use of good,
beautiful, bad, dreadful; one also notes a difficulty in finding the
expression with a tendency to awkwardly formed expressions of their
own invention.'^
Not only the manner of speaking, but epileptic thinking also has
something unclear and indefinite about it; the limitations of concep-
tions and ideas become blurred; general notions supplant the special.
Two different apprehensions cannot be kept apart. The definite
**
Many mere psychopaths have the same affective habitus as pronounced
epileptoid or as the less correctly designated epileptic character, especially when
the patients come from families with evident epileptic members.
*
Concerning moods that come like attacks see below.
*'
For illustrations see p. 83.
:

virtue of frugality is designated by the phrase, "Where one does the
right thing." A squirrel "is now a rabbit or a cat or a fox."Even
in mathematics 16 + 16 is "about from 32 to 34."
In speaking and writing we have the same peculiarities: The
patient does not get anywhere with his talking, not only because of
its slowness, but especially because of its circumstantiality, which must
depict all trivialities in repetition and in manifold expression of the

same idea in different forms. Besides this the manner of speaking is
verbose and clumsj'', and always vague. As to content the patient
clings to the simple and the present. The ideas are limited to what
immediately concerns the patient; his personality including the dis-
ease; then the members of his family ("family gossip," "family boast-
ing"), his clothes ("whining about clothing") and a number of trifles
which the patients, if permitted, like to carry about, usually packed

carefully in many papers or clothes, each carefully tied with a string,
as photographs, letters, a worthless ornament, etc. Affectively and
hence associatively, the patients are to a high degree egocentric. The
consciousness of their inferiority, the need of support and of putting
the salvation of their personality in the foreground, of clothing vague
ideas with pathetic, beautifully coined phrases, and also with intense
feeling all these give them the opportunity of assuming a vapid
piety in religious circles, and of dressing their weal and woe in corre-
sponding formulae ("God nomenclature"). With the unintelligent this
succeeds the more readily, because in their indistinct concepts and
ideas they are satisfied with generaliites to which they attach an
affective rather than an intellectual content. The egocentricity shows
itself, among other ways, in the fact that they are incapable of evalu-
ating the interests of others; whatever causes them joy and anger, they
consider similarly important and emotionally colored for others. It
is quite characteristic that frequently they take the physician aside
with a solemn mien to tell him secretly something commonplace or
something that was known long ago.
Perseveration and the difficulty of diverting them to another sub-
by Wernicke:
ject are illustrated in the following conversation reported
"What is "Martha Glockner." "How old are you?"
your name?"
"Martha Glockner." "Where are we now?" "Martha Flockner."
"How old are you?" "Twenty-two years old." "Where are we now?"
"Twenty-two 3'ears old." "What is your calling?" "Twenty-two years
old." "Who am I?" "Cousin George."
Circumstantiality and the tendency to tautology are shown in the
following letter (whose dialect and orthography have been extensively
corrected)
;
"My dear Director: I send you my best regards from the bottom of
my heart and wish you from the bottom of my heart good health and
God's blessing and I respect you and I thank you from the bottom of
my heart and I wished all of this for the director and the minister,
and I wished this all for your relatives all of this and I beg you from
the bottom of my heart that you send the letter to Riiti which I handed
in lastweek and the parents in Riiti I send. I sent my heartfelt wishes
also and I respect them too and thank them too and wish them from
the bottom of my heart good health and God's blessing and the sick
and the healthy also and I have the greatest home sickness for his
services and sermon and bible lessons and all prayer books were in
me. ..."
Ulrich gives a brief illustration of the unctuous emotionalism:
"I am the dear young lady Miss X. X. from X., Parish of X.,
Canton X., Switzerland." She wanted the physicians to explain to
her daily that she was the dearest and best Miss X. X.; she pressed
people's hands as much and as emotionally as possible, the left as well
as the right. She always wished one a dear good Sunday, a dear
good day of the week, whatever it might be, a dear good night's rest;
if one responded to her good wishes, she answered with satisfaction:
"That is the right way."

The egocentricity shows itself in the following answer to the ques-
tion, "What is the significance of Christmas?" "Last Christmas I
received an apron, I wanted a skirt from my mother; she did not
give it to me."
Thus the conduct of epileptics is to all appearances well regulated

but to those about them it readily becomes somewhat trying, as much
because of their fussiness, as their adhesiveness and their clinging
to trivialities. However one can very readily establish a satisfactory
and not unpleasant rapport with them; where one does not get on
with the average epileptic, there is some mistake in the treatment.
They are as clinging in their demonstration of affection as they are
persistent in their affect of offense. They do not release for a long
time the proffered hand; one forgets to greet them, it can dampen
if
their spirit for days. They busy themselves as long as they possibly
can even though not very much is produced; in the wards the more
demented patients actually become a nuisance on account of their
clumsy readiness to help during the war the same zealousness showed
;
itself in their "war spirit"; it made them forget any consideration of
their disease and led them to try again and again to reach the front.
When left to themselves, their unsteadiness is very great. Because
they take everything to be too important and especially because of
their moods, they cannot remainanywhere permanently many become ;
tramps. The momentary mood also dominates primarily their attitude

toward the disease, which is at times regarded as something very bad
and then as improved or cured. However, their main afflictions as well
as their various secondary ailments are always a matter of extraordi-
nary importance to them, which they like to discuss incessantly, be
it to obtain sympathy or help, or to boast of how well they are getting
on. But in the main the "epileptic optimism" (Rieger) prevails, that
is, even the more intelligent, in spite of all accidents and warnings,
never take permanent consideration of their disease; they get into

situations that are dangerous to themselves or undertake work and
responsibilities that they cannot possibly carry out.
The attention of epileptics, corresponding to their affectivity, shows
a reduced vigility (distractibility), but a good tenacity; at the same
time it is very uneven at different times.
Even though many details, especially affective experiences, are
remembered for a strikingly long time, nevertheless the memory after a
while becomes bad but not in a recognizable systematic way; recent
and old impressions are equally forgotten. Besides, it becomes blurred;
experiences are associated with other connections; frequently it goes
as far as actual memory illusions (the amnesias belong to the
paroxysmal state).
Orientation, except in conditions of most advanced dementia which
only a few attain, and in twilight states, is good.
Perceptions readily become unclear; like organic cases the patients
require more time than normal persons and easily make mistakes.
Furthermore, the after-effects of previous influences interfere (Persev-
eration) . For example, they mistake a picture in terms of a previous
visual impression. But the unclearness of the perception is not a result
of inadequate peripheral sensory functioning; the patients are at least

capable, despite their fussiness about minutise, e.g. of distinguishing
the differences between two similar lines, much better than are healthy
people. Often the patient cannot follow complicated relations and
rapid changes of ideas. Sometimes there is a big difference between
the conception of single words and an entire sentence.
The speech of epileptics is often so characteristic that the diagnosis
can be made from it; it is slow, hesitating, in which case syllables are
often repeated several times and the patients cannot make any prog-
ress.^* Because of the slowness, and because the individual vowels
**
To differentiate it from stuttering it does not show any spasmodic mani-
festations of the speech muscles.
often show a rising and and the unaccented syllables are

falling
stressed as much becomes somewhat sing-
as the accented, their speech
song. With this the tonal modulations are clumsy and rare, hardly
ever finely shaded, so that the speech at the same time seems somewhat
monotonous. The degree of these speech disturbances may var>'
decidedly in the same patient: at the approach of an attack or in a
twilight state it is usually particularly pronounced.
Chronic hallucinating hardly ever occurs in epileptics. On the
other hand, under the affective influence delusions are very frequently
formed, especially of being treated unjustly. As a rule they are for-
gotten or corrected in the next opposite mood, but, like the delusions
produced in the twilight states, they may, in exceptional cases, have
a longer duration.
Besides symptoms of permanent epileptic degeneration, we regu-
larly find in the psychical field also transient manifestations which,
at least in part, are certainly equivalent to the attack. In the course
of these, the permanent symptoms are especially pronounced.
In the first place we find the twilight states which most frequently
occur post-epileptically, but may also take place pre-epileptically and
instead of the attack ("Equivalents"). They usually begin quickly,
often very suddenly, and disappear again within a few minutes or
hours, after having lasted for hours or days. Epileptic deliria, lasting
for weeks or even months, are rare. The most frequent form is the
hallucinatory delirium. The patients hallucinate and have illusions,
especially of sight, but also of the other senses, concerning another
environment, or at any rate, other influences from without, and react
to these. Among the hallucinations red ones (partly as fire or blood)
occur with noticeable frequency. The content, in other respects, is
very similar to our dreams. A part of the deliria is alTectively indif-

ferent. More frequent are those with an anxious or angry affect
which readily lead to brutal acts of violence against the individual
himself and others; sexual excitements are the basis of Ripper murders,
or frequent exhibitionism. Besides fearful visions of hell and the
devil, there occur much more rarely ecstasies which are completely
beyond the reach of reality and blissful erotic-religious hallucinations
of all the senses. Pronounced twilight states can be influenced ver>'
little; but under certain conditions one can get in touch with the
patient; however, one gets few answers, and few sensible ones. Think-
ing is usually profoundly disturbed ;
^^ very simple answers are more
easily obtained than complicated ones; under certain conditions the
patient can figure 7 plus 18, but no longer 7 times 18, because he can
"See also p. 83.
no longer add 56 and 70. The associations run toward side-tracking
as in dreams, while in other respects the heavy, everywhere halting,
epileptic train of thought is strongly differentiated from dream think-
ing and schizophrenic thinking in spite of its inexactness in disarrange-
ments of ideas and words. Sound associates also occur in many
patients but not actual flight of ideas. The twilight states leaves, in
most cases, a partial or complete amnesia.
Between the attacks, milder states of obnubilation are most fre-
quent, in which sensory deceptions are entirely absent, orientation as
to place and time is disturbed little or not at all; on the other hand,
the relation with surrounding persons is usually falsified. Hostile
attitudes are very common. In the most common types there is a
feeling of pressure to talk, together with strongly retarded thinking
and impeded word selection, and vague, unclear, poorly defined ideas.
At the same time sound associations and the reception of chance
material from without into the trend of ideas which never leave the
same circle may simulate flight of ideas for the beginner. Persevera-
tion and the absence of real distractibility readily reveal the true
condition. Vagueness of apperception leads the patients to mistake
persons, so that they even identify themselves with others in
transitivism.
Outwardty very different are the clear twilight states in which
the patients seem clear to the observer but are, in reality, extremely
restricted associatively and carry out any dreamlike action.^"" But
with Heilbronner I would like to attribute most of these conditions
to hysteria, even when they occur in epileptics as they not seldom do.
Sometimes a patient suddenly finds himself on a street where he did
not want to go. Mere anxiety attacks are often epileptic equivalents.
With a slightly consciousness pseudo hallucinations
clouded
(especially of sight) may
appear in the form of attacks, e.g. figures
also
who with long arms reach for the patient, an animal, the devil, or
when in a pleasant mood, angels, or beautiful women.
A twilight state may form of a stupor of varying
also take on the
degree, or continuous identifying memory deceptions may dominate
the picture.
Furthermore somnambulism may be a (rare) epileptic symptom.
Of especial importance are the moods which are probably not
lacking in any epileptic (but which also occur in other psychopaths,
oligophrenia, and in schizophrenia). There may be euphoric moods
of especial good feeling, often with the idea of being finally cured of
the epilepsy, but without flight of ideas (usually as a precursor of
""See p. 112.
attacks). Or depressive moods with or without fear which resemble

completely a melancholic mood, relatively seldom with a suicidal
impulse but very frequently with the emphasis on the incurability,
or it manifests itself in the best known mood, namely irritation, in
which, on the one hand, the patients are irritated by everything that
takes place and, on the other, conduct themselves in a very presumptu-
ous and impudent fashion so that conflicts are unavoidable. The moods
may appear suddenly and be suddenly brought to an end (especially
by an attack, the precursor of which they then were), or they may
appear furtively and last hours or several days and rarely even
longer.
Mere common, especially headache, pains
paresthesias are also
here and and
there, any kind of nervous manifestations which dis-
tinctly show the paroxysmal character; furthermore, one observes
stomach troubles, that appear and disappear suddenly, attacks of
passion with or without impulsive onanism or attacks on others, also
twitchings and other manifestations of spasms. The irregular fluctua-
tions of a more severe tremor which are frequently found in the graphic
registration of epileptics are also included here.
All these syndromes may
occur in isolated form or irregularly inter-
mingled; furthermore, like the attacks, they often repeat themselves
in a similar or actually identical form.
In the physical field also we find anomalies that belong to epilepsy.
In the first place a number of congenital malformations show the
"degeneration" or the brain disease.
In the blood are found cytological and especially chemical peculiari-
tieswhich, however, fluctuate greatly in the same patient, and still
more in different cases so that as yet no clear picture can be obtained.
The entire metabolism and with it the chemistry of the urine is abnor-
mal, but cannot as yet be described in a uniform manner. It seems
fairly certain that after the attack poisonous substances are excreted.
It is known on what the
not sensitiveness to alcohol in the most vari-
ous ways is based; however, it can be connected with the intolerance
of alcohol after injuries to the brain.
Like the other nervous processes, movements are often performed
slowly, clumsily, and perhaps also with uncertainty. But bodily
strength remains for a noticeably long time either good or very good.
The course of the disease is, on the whole, progressive, at least in
respect to the permanent psychical condition. The attacks need not
increase; often they even become milder or rudimentary^ in time. A
between the number and severity of the attacks and
direct connection
dementia does not exist. Marked dementias may also appear with
;

a simple petit mal. Some cases remain stationary, others become
cured, especially with suitable treatment. Pauses extending over years
or decades are not so rare; it is well known that there are patients who
have attacks in earliest childhood, then seem cured, only to be afflicted
again during puberty. Among the milder cases many recover defi-
nitively, others only from the attacks while the epileptic character
remains, or under certain conditions even develops more strongly
together with intellectual dementia. There are also epileptics who
have quite a number of attacks every year and nevertheless with

or without therapy do not become demented and whose character
remains relatively good.
The number of attacks differs greatly. In milder cases only a
few convulsions and twilight states may occur during their whole life
others produce several in a single day; in especially bad times they
even have many, rarely a hundred and even more. Many patients,
especially in the beginning of the disease, are stricken, only or chiefly,
during the night and do not at know
that they are epileptic. In
all
some the attacks are scattered, they appear more in series.

in others
The prospects in case of a pronounced, interparoxystical dementia
are naturally bad, even though at times a regulated therapy produces
improvement to the extent that the subsidiary manifestations dis-
appear. A certain percentage, especially of those afflicted after
puberty, lose the attacks spontaneously and become little or not at all
demented."^ Undoubtedly a timely interference may extensively
improve many a case or even cure it and prevent further decline.
Here the prospects depend especially on the psychic condition. Ex-
tensive improvement or cure can be expected only in case of a slightly
affected psyche.
The duration of life is considerably shortened by the disease.
Many meet with an accident during the attack, others die from an
early marasmus which is regularly connected with more severe de-
mentia and cerebral atrophy. Epileptics who from birth were afflicted
with some brain disease naturally have a weak physical endurance.
Anatomical Findings. Epileptics are comparatively rich in stig-
mata of degeneration ^^ and other dysplasias strikingly frequent one
;
observes in the brain among other things ganglion cells in the white
substance, Cajal's (foetal-) cells in the upper cortical layer, as well as
other disturbances of development. As a foundation of the later de-
mentia one finds a distinct, even though not a high grade atrophy of
"^ I have a decided distrust of the diagnosis of epilepsy in Mohammed,
Socrates, or even Napoleon.
'"'
Cf. pp. 159-160.
the brain with different fonns of degeneration of the neurons, and as

characteristic,an increase of the glia fibres, which, as distinguished
from paresis, remain on the whole fine, usually arrange themselves in
bunches in the interior of the brain and cover especially the surface
with a thick felt of chiefly tangential fibres, which have little connec-
tion with the deeper layers. The glia cells are changed in different
ways, readily increased and carry many catabolic products. What
relation these findings have to the disease is still entirely unknown as
is the significance of the frequently found sclerosis of one or both of
the ammon horns with degeneration of the nerve cells and hypertrophy
of the glia.
In death following status epilcpticus one finds, as a rule, a higher
pressure in the cranial cavity partly because of cerebral cedema and
especially of the meninges, partly, too, probably because of cerebral
inflammation.
Causes. Epilepsy has its roots in the congenital constitution.
Hereditary burdens with mental diseases, psychopathic conditions
with familiar nervous degeneration and especially with epilepsy itself,
show the connection with a diseased kin. That the "epileptic char-
acters" in such families often represent milder forms of the same dis-
ease is to be assumed. The various kinds of epilepsy, also, have un-
fortunately not been kept separate in the investigations of heredity.
An important role is played by the alcoholism of the parents, probably
that of a cause and not merely as a sign of a morbid family disposi-
tion.^"^ According to more recent investigations epilepsy is supposed
to have a connection with the familiar left-handedness, and not merely
because left-sided brain lesions at the same time dispose to left-
handedness and to epilepsy. 'Âs the Wassermann reaction shows in
early epilepsy, many cases are based on hereditary lues. In the
individual life epilepsy may be acquired from every possible brain
disease, from the uterine porencephalus, the infectious encephalitides,
and the traumata up to arteriosclerosis (the latter, however, is rela-
tively rare) and from all sorts of poisons, especially alcohol and lead.
,
Whether an epileptic disposition must have existed in such patients is

not yet known. If a brain lesion is once present, cocain can precipi-
tate an epileptic attack which may then repeat itself. (Caution! Ac-
cording to Ulrich, Novocain may on the contrary be used as a local
anesthetic.)
The causes of the individual attack are, as a rule, internal; never-
^'^
Stuchlik, tjber die hereditaren Beziehungen zwischen Alkoholismus und
Epilepsia, Diss. Zurich 1914, und Korrespondenzblatt f. Schweizer Aerzte. Basel
1914.
theless psychic influences can hold back and precipitate attacks (a
festival, remedies with a suggestive effect)."* However, ordinarily
the anger which is supposed to have released the attack is not the
cause but the precursor ofit. In his moodiness because of impossible
demands, presumptuous conduct and irritability, the patient has

brought about the anger. Individual attacks are often precipitated
by excesses of all kinds and even by relatively slight alcoholic in-
dulgence. The famous moon phases have no influence; on the other
hand atmospheric conditions seem to be able to effect slight fluctua-
tions in the frequency of the attacks.
Forms, Range. As yet we have too little anatomical experience
to differentiate the described groups sharply from other diseases with
epileptic attacks. Especially must the question be raised whether
all the "curable" cases, or those running their course with unnotice-
ably little dementia, or the very mild cases, generally are identical
with the inevitably progressive ones. As an uninterrupted shading
from the most favorable to the worse cases is perceptible, it is possible
but not certain that all or many of the curable and (apparently)
stationary cases represent only milder forms of the same disease.
Cases with entirely different symptoms (more acute degeneration of
the nervous substance) are naturally to be excluded eo ipso.
Traumatic epilepsy as a result of injuries to the brain frequently
resembles the forms described, but it is quite evident that the organic
dementia frequently contains an admixture of the psychic and physical
signs of cerebral trauma. There are also milder cases which improve
or remain in a quiescent state.
The
reflex epilepsies cannot as yet be assigned to any classification.
Jacksonian epilepsy is not an epilepsy in our sense; but it very
often is transformed into such as the attacks assume the epileptic
type and the psychic manifestations change their nuance in the sense
of epilepsy.
In arteriosclerosis and presbyophrenia the epileptic attacks are
probably only partial manifestations of the main disease although in
one case of arteriosclerosis I also found the epileptic gliosis.
In the same way the epileptiform attacks of schizophrenia naturally

belong to this disease. But there are noticeably many patients from
whom one gets the impression that schizophrenic and epileptic symp-
toms have intermingled.^"^
"* According to Hauptmann one observed (that is, in the milder forms) no
epileptic attacks in the war during an alarm or charge attacks (differs from
hysterical attacks).
"=Corap. p. 446.
Kraepelin also distinguishes a "Residvxil epilepsy," recurring epilep-

tiform attacks without a progressive course in brain scars and similar
disturbances.
The eclampsia of children often resembles the epileptic attacks;
but the tonic stage is often more strongly, the clonic much more
weakly, pronounced. But as most do not become
of those children
epileptics, it is not known whether the two diseases are connected and
in what way they are related. Spasmophilia is no primary stage of
epilepsy.
Dipsomania and alcoholic epilepsy^'"^ Most dipsomaniacs do not
seem to become severely demented, even when they have the epileptic
habitus.
On the basis of two clear cases Kraepelin would like to class with
epilepsy the running amok of the Malays, in which the patients sud-
denly run through the streets with drawn daggers, cut people down
at random until they collapse or, which is more frequent, are shot
down or made harmless in some other way. The monotonous repeti-
tion of the same psychic syndrome in the various patients seems to me
^^
to point to the material influence of a psychogenic factor.
Friedmann's Disease, which the author wants to designate with
the already assigned name of Narkolepsy, consists of very frequently
recurring attacks of prolonged psychic rigidity or confusion without
loss of consciousness with a turning upward of the eyes. It occurs in
children and disappears with age without dementia. Kraepelin would

like to class this disease with hysteria. At all events it does not belong
to our genuine epilepsy as some authors suppose.
Many also want to include Migrain with epilepsy. But it is a
syndrome which may occur in the most varying functional and organic
diseases of the nervous system.
On the other hand, the affective epilepsies (Bratz) or reactive
epilepsies (Bonhoeffer) are important psychopathic states with strong
affectivity, inwhich psychic influences may more or less frequently
lead to epileptiform attacks. Kraepelin observed them especially in
unsteady people who were inclined to wander and swindle, and he
calls these epileptic swindlers. Bromide does not seem to influence
affective epilepsy in the same specific way as it does the genuine form.
Occurrence. Epilepsy in the older, wider sense of the term, to

be sure, is a frequent disease in all ages and in all races. "With us
undoubtedly several per thousand of the population suffer from the
"' See Alcoholism, pp. 351-352.
^'"
Cf. Brill, Piblokto or Hysteria Among Peary's Eskimos. Journal of Nervous
and Mental Diseases, Vol. 40, No. 8.
disease. According to whether or not one includes the infantile con-
vulsions, most cases begin in the first or second decade. The male
sex predominates considerably, particularly when the disease appears
in mature manhood; here it is evidently a result of alcoholic effects.
Recognition. In many cases the patients report nothing, or nothing
characteristic, concerning the attacks. They come to the physician
because of nervous symptoms, changes of character, unrecognized or
abortive twilight states; then the recognition is not easy. But fre-
quently they bring with them a complete diagnosis or a clear anamnesis.
Even though the individual attack does not permit of recognition,
nevertheless a disease in which for years such attacks have occurred
in somewhat definite intervals is invariably an epilepsy, and if there
is nothing important in addition, it will be a genuine epilepsy. The
positive findings of the psychic symptoms will in most cases quickly
confirm the diagnosis. Typical absences, except at times in brain
tumors, occur almost only in epilepsy and are, to that extent, more
characteristic than the big attacks. During epileptic excitations, but
also in more advanced chronic conditions, the slow, hesitating reaction
is usually especially evident as against other disturbances (except
the organic) :
^^ "A patient who responds quickly to all my objections,
is not an epileptic" (Vogt) ! Often the anamnesis can contribute much
to the clarification. It offers evidence that the attacks already existed
earlier, or narrates experiences that point in that direction, such as
isolated bed-wettings in later years, falling out ofbed during sleep
(usually without waking up)
knocked out in the morning,
, feeling
tongue bites of unknown origin. But one must not expect to find
frequently tongue scars; even severe wounds of the tongue sometimes
heal without a mark; scars from injuries to the body are more fre-
quent. Heredity of a similar kind may also be considered.
Under certain conditions the dift'erential diagnosis from an
organic mental or brain disease may for a time be difficult, because,
aside from the convulsive attacks and absences, the psychic symptoms
(associations and attacks of confusion) of the two morbid groups
may also be similar. In this case, after a minute physical and
psychic examination, the discovery of the specific signs of one or the
other disease must finally decide.
From dementia proecox, aside from the mentioned mixed or transi-
tion forms, the diagnosis is usually easy. In the twilight state one
should notice especially the hesitating speech ; furthermore the uniform,
clear and real affective state in the epileptic, as against the artificial
state of the schizophrenic which is difficult to interpret. The difficult
"' Cf . also brain injuries.

distractability must not be mistaken for affective rigidity: if I can

violently deprive a person in a euphoric twilight state of his beloved
trifleswithout his changing his affective attitude even a little bit, this
behavior differs from the schizophrenic attitude by the fact that the
epileptic defends himself but in reality is not distracted at all, even
intellectually. He has therefore no reason for changing the affect.
Minor traits by themselves may also often facilitate the diagnosis
or make it certain; thus an apparently totally confused person in
motion, who in this state continually handles in both hands a care-
fully folded handkerchief without disarranging the folds, is probably
always an epileptic.
Among the more striking symptoms the following are common
to both diseases: the tendency to symbolism, unclear ideas, and
neologisms. But as a rule the symptoms are plainly distinguished by
different nuances. The symbolism of epilepsy does not lead to the
fixed delusions or even to hallucinations, as in schizophrenia. It
remains rather a peculiarity of thinking. In schizophrenia the indefi-
niteness of the ideas and conceptions is altogether unbalanced. Besides
the most senseless conceptions many entirely normal ones occur,
while the demented epileptic finds it difficult at all times to create
clear limitations. The epileptic neologisms consist rather of poor
word formations than in genuine new creations; ''unquitted love" is
probably an epileptic formation: "Dossier path" for the secretive

manner of persecution and "Anona" for morphine are schizophrenic.
Mistaking an epileptic crepuscular attack of rage for the manic
destructive impulse is avoided, among other things, by the absence
of distractibility and flight of ideas (but one must not associate the
circumstantiality in which the patient is not distractible and does
not forget his goal as well as the liability to interruption, with the goal-
shifting flight of ideas).
The attacks are well distinguished from the hysterical; it is
especially important to think of the tonic-clonic type, the brief dura-

tion of these phases, the tongue biting and other injuries, and the
rigidity of the pupils. Involuntary passing of urine and feces hardly
occurs in an hysterical attack. Ankle clonus or the Babinski sign
after the attack excludes mere hysteria. According to Bosshard^^^
in a pronounced epileptic attack there is regularly found a leucocytosis
which differs from the "work-leucocytoses," by the early appearance
of lymphocytosis and mononucleosis. Under certain circumstances
the pulse, remaining good in spite of an apparently serious condition,
gives evidence of hysteria; also the facts that the patients are accessible
" Uber Leukocytenvermehrung bei epilept. Anfiillen. Diss. Ziirich 1917.
to influences, the consideration for themselves and^ others when
struggling and falling, as well as the reacting pupils, all these ele-
ments are foreign to the epileptic attack. The marked dependence
of the hysterical attack on external influences, and the slight dependence
of the epileptic syndromes, can with a careful evaluation of circum-
stances often alone suffice for the diagnosis. In all other respects it
should not be forgotten that in epilepsy all hysterical symptoms may

occur.
The same signs help to distinguish the attack from simulation.
Attacks of dizziness may also occur in the nervous, arteriosclerotics,
and generally in all brain diseases, even though rarely in the same
development as in epilepsy, with the brief duration, and the sharp,
sudden limitation.^^"
Under certain conditions it is impossible for the moment to distin-
guish the epileptic twilight state from the pathological drunkenness,
especially because epileptiform attacks occur in both, and alcohol may
precipitate epileptic syndromes.
From the epileptic twilight state to the moods and excitations of
oligophrenics there are so many transitions, that under certain circum-
stances the question has to be left open for some time, whether mere
oligophrenia or combination with epilepsy is present.
In judicial cases one can resort, with the patient's consent, to the
remedy of having the patient take bromide in medium doses for
about three weeks, then suddenly stop the drug and give him well
salted foods, or besides the foods, at least one ounce of cooking salt
in one day. In latent epilepsy this may sometimes provoke an attack.
The pathology of genuine epilepsy is, in spite of all the works
devoted to it, still entirely unknown. It may be a constitutional
degeneration of the brain, something teratological; the frequent
physical stigmata of degeneration, the Cajal cells and the other brain
findings, which may, however, be secondary, would point to this. In
accordance with the present humoral pathological views, it or at least

the convulsive attack with its equivalent is to be considered a result
of an autointoxication. The chemical examinations of the blood and
urine favor this in spite of their lack of uniformity, but above all the
observation, that when in patients that have preparoxysmal moods
the attacks are suppressed with bromide, these moods are easily pro-
longed until an attack is permitted. The convulsive attack, therefore,
seems to have the significance of a crisis, and as the urine is said to
be more poisonous immediately after the attacks than otherwise, this
crisis might be chemical.
"" For absences, compare above, pp. 447-448.
One can also think that tlie brain pressure which can be verified
in the status epilepticus may have something to do with the epilepsy;
but it is well, however, to differentiate the known clinical manifestations
of brain pressure from epilepsy.
Physiologically one must conclude that the brain cortex and
deeper locations together participate in the production of the attack.
Treatment. Nothing can be done by way of prevention except to
hinder the marriage of degenerates, and work against alcoholic
indulgence.
In the treatment of the disease itself bromide is the most important
and the only chemical remedy of significance. It is given as potassium
bromide (the cheapest) or as sodium bromide, which avoids the effects
of the potassium which, however, are not very noticeable, or it may
be given in the form of a mixture of ammonium, sodium and potas-
sium bromides in equal parts in doses of from 3 to 8 grammes a day
(in children, of course, correspondingly less). One tries the dose after
which the attacks disappear or are reduced to a minimum; in the
beginning, perhaps in the course of the first year, it may be reduced
a little, but later this dose is retained continually for years; best of
all forever. Omissions and variations are soon paid for in the cases
that can be influenced. A fatal status epilepticus often follows a
sudden omission. is It important that the salt be given largely diluted,
about two decileters per gramme, because otherwise the stomach is
affected, and the patient too easily becomes tired of the remedy.
The effect can be increased bj^ the reduction (not deprivation) of
table salt (from 5 to 10 grammes per day). As a large quantity of
it istaken up in soup, about 20 grammes, the latter may be salted
with bromide or most palatably, by substituting a bouillon of sedobrol,
a combination of sodium bromide and soup spices. In this form the
remedy is gladly taken, does the least harm, and otherwise, too, seems
to have the best results. In severe cases Ulrich gives successfully
Sedobrol combined with Chloral-hydrate 0.5 to L5 grammes daily,
given in the evening, especially in night attacks.
Bromism is usually better combatted by doses of table salt than
by larger reductions of the bromide or its withdrawal (furthermore
by arsenic; in case of open wounds mercury plaster or mercun.-
ointments).
Not only the regular taking of the remedy but the regulation of
the whole manner of living is important, in w^hich excesses in all
directions, in work, food, drink, recreation, and affective stimuli, must

be avoided. Alcohol, even in small doses, must be forbidden. Other
stimuli like caffein and strong condiments, as well as meat diet, should
be restricted; in many cases a diet with large quantities of milk seems
useful. To recommend marriage, as is often done, and not only by
the laity, should be branded as a crime.
Some cases which do not respond to bromides may improve by
Luminal taken evenings in one dose of 0.05-0.01. It can eventually
be combined with bromides. But one must not continue to give this
narcotic for years, and like bromide it should not be suddenly stopped.
As without confinement epileptics readily make the rigid enforce-
ment of the treatment difficult because of their moods and fits and
strong reactions to light discomforts, it is often wise to have them
put into an asylum where the stay should last many months, a year,
or even more.^^^ If one sees that a substantial gain can no longer be
obtained with bromide, which is usual in the advanced cases, who
e.g. hang on in the insane asylums, it should be given up. Where
medications do no good there is always occasion for friction with
these moody and when a status makes the use of bromide

patients,
necessary it is obviously more effective in patients not habituated to it.
Of the numerous surgical interferences already undertaken against
epilepsy, there have survived only the operations for irritating
peripheral scars (a very rare cause of epilepsy), of brain scars and
exostoses of the inner cranium, and "pressure relief" by trepanation
with the greatest possible prevention of new bone formation. But
these cases too must be treated with bromide before and after the
operation.
In epilepsy after brain injury severe physical and mental exertion
favors the appearance of attacks. Therefore, when possible, the
patients are kept busy much under the maximum of their capacity.
In exceptional cases the single attacks may be checked by binding
of the member in which the aura appears with an Esmarch bandage,
or by extending an aura convulsion. Other interferences, from with-
out or from the patients themselves, are at times successful only in
exceptional cases. Usually the attack must be permitted to run its
course. Against the status epilepticus amylenehydrate (in form of

an enema in some vehicle) in doses from 5 to 6 grammes is effective;
perhaps still better is bromide plus chloral hydrate (e.g. Potassium
Bromide 2.0, chloral hydrate 1.0 to 2.0, to be repeated every half
hour up to the maximum dose of chloral), perhaps combined with
baths of almost body temperature.^^^
"* For details, see Ulrich, Beitr. zur Techn. der wirks. Brombehdlg. Korresp.
Bl. fur Schweizerarzte. Basel 1914, Nr. 21.
"- In the local asylum for epileptics as a result of the bromide treatment with
a reduced salt diet no status has occurred for years.

Against injuries during the attack nothing much can be done pro-
phylactically except to
warn the patients usually in vain to be sure
not to get into situations in which an attack may become dangerous.
When a certain part of the head is repeatedly injured, it can be pro-
tected by a protective covering. Careful supervision can naturally
prevent many accidents, but not all. Patients whom the aura warns
of the proximity of the attack often still have the time to get themselves
into a secure position or to call the protecting orderly. Besides obvious
measures he has to be especially careful that the patient does not
choke in the state of sopor when the tongue falls backwards.
XI. MANIC-DEPRESSIVE INSANITY

^^^
Group of the Affective Psychoses
In not a small number of psychoses, displacements of moods are in

the foreground and the remaining fundamental symptoms can fre-
quently be so exactly deduced from the affective anomalies that mild
cases cannot be distinguished symptomatically from normal affective
fluctuations. On closer inspection, to be sure, other cases show that this
explanation is nevertheless not sufficient, and that the disturbance of
the affect represents merely the most conspicuous symptom of a
general transformation of the psyche that cannot as yet be compre-
hended. The diseases are not progressive and never lead to a dementia
that could be compared with that of the organic, epileptic, and schizo-
phrenic forms. As to the affection of the intellectual activity it is a
question of equalizable disturbances, which for the most part look
like the accompanying intellectual manifestations of exaggerated
affective fluctuations.
According to our present knowledge the basic symptoms are:
1. Exalted or depressive moods.
2. Flight of ideas or retardation of the mental stream.
3. Abnormal facilitation or retardation of the centrifugal functions

of resolution, of acting, inclusive of the psychic elements of motility.
Euphoria, flight and pressure activity on the one hand
of ideas,
(mania) ; and centrifugal retardation on the
depression, associative
other hand (melancholia) are the most frequent combinations.
, In
the cases that reach the psychiatrist these syndromes nearly always
occur in the forms of attacks and the intervals seem to be about
normal; but it may also be a case of a persistent peculiarity which
is then invariably of a lesser degree. As accessory syryiptams there
^ Not to be mistaken for the reaction psychoses.


occur also delusions and hallucinations (almost only of hearing and
sight),and "nervous" manifestations.
The Manic Attack. The mood of the manic attack consists of an
exalted feeling of self, euphoria, and cheerfulness. The patients feel
happy, "overjoyed"; and experiences are colored with pleasant feel-
ings; they are insensitive to depressive experiences; minor "unpleas-
antnesses" are more readily felt, and especially everything that hurts
the patient's enhanced feeling of self; and because in his over-estimation
of himself he is constantly making demands that cannot be fulfilled,
he is always in a state of discord, anger and rage, with his environ-
ment. Moreover, the mood of the manic is very fluctuating; with great
outbursts it follows every slight variation of the imagination, but in
pronounced mania it does not easily descend by way of reaction to
the depressive or anxious. On the other hand, endogenous reversals
to depression, that last a quarter of an hour, an hour, or sometimes
two days, are not at all rare. Sensitiveness to physical pain is not
directly reduced. To be sure, the patients frequently do not notice
pains; when, however, they have e.g. to be subjected to a slight
operation when the attention is directed to the injury, they can even
be very tender.
The thinking of the manic is flighty.^^* He jumps by by-paths
from one subject to another, and cannot adhere to anything. With
this the ideas run along very easily and involuntarily, even so freely
that it may be felt as unpleasant by the patient. In severer cases the
patient is also bothered with a consciousness of unclearness, and an
inability to arrange his thoughts and think them out. Aside from the
severest forms only, where it looks as if the patient's speech and finally
the listener's intelligence could not follow the wild racing of the ideas
(flighty confusion), one finds as a rule the thread that connects the
individual ideas. not in prin-
It is not a case of incoherence, at least
ciple. The thinking is incomplete and flighty but not "unclear" in
the sense of psychopathology. Up to advanced stages of the disease
one can converse with the manic, and more than in his normal times,
he displays a rapid grasp and evaluation of the opponent's weakness,
giving quick, witty, or sarcastic answers, or pettifogging logic.
Transiently in the course of an attack one may observe a disturb-
ance of thought having a certain similarity to a dream.^^^ It may
persist for hours or days, in exceptional cases also during the entire
phase, and shows subjective or objective unclearness of all ideas and
logical connections, the nature of which has not yet been studied.
"*See p. 71.
'""
To be distinguished from complicating hysterical trance-conditions.
Disturbances of apperception do not become noticeable in ordinary

intercourse. Reactions to remarks and changes of situation generally
are rapid and from the patient's point of view correct. To be sure,
in an experimental test, the patients make many
errors, which, how-
ever, are to be accounted for by and not by an actual
"flightiness,"
disturbance of perceptions. The orientation as to time and place,
except in the severest cases of flighty confusion, also remains undis-
turbed. Naturally, the situation is invariably incorrectly estimated,
inasmuch as the patients usually consider themselves "particularly
well," and in any case cannot understand the restrictions of their
freedom of action.
The attention is characterized by an extreme distractibility from
without and within.
Just as the ideas readily appear and crowd up, they also translate
themselves readily and of necessity (but without a subjective feeling
of compulsion) into resolutions and actions. Interest in everything
is at the same time leveled upwards A thought is aroused; without
any consideration for the object of thought at hand, it is pursued until
it is supplanted by another. The patient sees something and grasps
it; he notices that the physician wears a glass eye and at once calls out
in the first moment of meeting: "But you only have one eye," which
the one-eyed Dr. Jolly Sr. makes use of in diagnosing his cases; the
idea crops up that something should be done, and without the notice-
able intervention of consideration and resolution, he acts. Obstacles
are not felt. The patients cannot be without occupation; they suffer
from pressure activity.
The external picture varies according to the severity of the disease
from mild manic excitability to "frenzy." In the submanias the patient
is more active than usual in small and big affairs he gets many plans
;
that he at once seeks to carry out; he gets up especially early to take

long walks or take part in some athletic sport; he makes inventions,
poems, wants to improve something in the universe, mixes in every-
thing imaginable that does not concern him, travels about, or enlarges
his business; his mother's burial becomes an extraordinary- festive
arrangement. A bank employee, w4ien w\ar threatened, made pro-
posals to his government for securing the supply of silver, and suc-
ceeded in being sent to Rothschild in London. A young girl for the
firsttime comes to a federation of women's clubs and as a president
of the federation is being sought, she at once indicates that she is
prepared to accept. In associating with strangers or persons of note,
the sub-manic may conduct himself as if with intimate friends.
Because of lack of restraint and his presumptions he gets into trouble.
Often during the entire duration of the attack he indulges in litigations.
But his good nature also manifests itself in a particularly lively
fashion; a bug alone on the street arouses the patient's sympathy, and
he carries it to a bakery where he buys a trifle in order to let it loose
there. Against excesses of all kinds, especially sexual, alcoholic,
wastefulness, inhibitions are lacking. When called to account, the
patient not only has excuses but "good reasons" for his conduct ("folie
raisonnante") . Because of the more rapid flow of ideas, and especially
because of the falling off of inhibitions, artistic activities are facilitated
even though something worth while is produced only in very mild

cases and when the patient is otherwise talented in this direction.
The heightened sensibilities naturally have the effect of furthering this.
If in the rather higher grades, institutional treatment becomes
necessary, the patient keeps the ward, the physicians, and the attend-
ants constantly on the go. He makes jokes, wants to help, finds many
arrangements very fine, but wants to make improvements; he protests
against the "restraint" even to the extent of severe outbursts of rage
with the destruction of everything within reach; but violent acts
toward persons are noticeably rare, except perhaps occasional slaps in
the face, At night the patient keeps on singing, or makes a doll
etc.
of life size out of the bed, etc. Female patients, in greater numbers
and more regularly than the male, are conspicuous for their marked
eroticism, going as far as the most shameless acts. In spite of all, one
can easily get a good rapport with the patients, as if with spoiled
children, whom one likes. ("How goes it with you?" "Very well.
Everything pleases me and I can run well," "Run" being a fiighty

association to the verb "goes" in the question.)
In the highest grade of mania frenzy (Tobsucht) appears perma-
nently; the patients are in "incessant activity," tear up, destroy, in
order to construct with the remains anything at all, a costume, a statue,
a relief of Switzerland; they smear, scold, howl, sing, hop; nothing is
completed, one "fragment of an action" supplants the other. The

expressions do not become really senseless.
In all forms, it is only by way of exception that one does not find
a great talkativeness up to incessant logorrhcea as a partial manifesta-
tion of the pressure activity. In severer cases the sentences are no
longer completed, because before that can be done there is always
a new idea to be expressed. Citations from all available languages
are intermingled; occasionally, too, a new language is invented. The
hand-writing shows the same disturbances, there is flightiness, uneven-
ness, mixture of various languages; the writing is helter skelter, all
sorts of things are sketched with it; in spite of many attempts at
;
THE INIMVIDUAL MENTAL JJISEASES 469
aesthetic decoration, sometiiinf^ very dirty and disorderly is finally

produced. But above all the hand-writing shows the patient's excita-
bility, a very important attribute in respect to the treatment: a large
part of the writing is in the beginning, entirely or relatively, weil
arranged and then becomes more and more morbid. Excitability is
a very general attribute in mania. The patients are quieter, the fewer
the stimuli affecting them, and the fewer their opportunities to express
the impulse to activity. The curve of hand-writing pressure shows
energetic and rapid movements. More exact examination of motility
shows that the movements progress easily and quickly the maximum ;
of strength, at least in ergographic tests, is less than in the healthy.

It is the lack of consideration for everything and the psychical energy
of the movements that make the patients appear stronger; this is
especially accentuated by the endurance and the absence of a feeling
of exhaustion.
As accessory symptoms in these ordinary forms of mania, there
are also illusions and hallucinationc of sight and hearing, more rarely
of smell and taste (touch or bodily sensations are hardly ever present)
but they have little influence on the picture. Ideas of over-estimation
are rarely absent, and frequently it goes as far as delusions of grandeur,
the content of which does not really become senseless, but remains at
least imaginable. The most absurd grandiose idea that I saw was that
of a Swiss who thought he would become emperor. But one must
take great care not to mistake ordinary playfulness for delusions, for
which the patients very readily give occasion, especially so in their,
every day "mistaking of persons." The patients designate the people
about them with other names, which is often based on any slight in-
ternal or external resemblance, and retain the fiction for a long time;
but if one remains suspicious one can probably offer proof in all cases
that it is a case of some kind of joke. On the other hand, the feelings of
being injured and unjustly treated may often resemble a delusion of
persecution, which, however, at the first glance is usually distinguished
from the paranoiac and paranoid delusion of persecution by a lack
of fixations and by the whole manner of expression.
Nervous symptoms are vers' rarely lacking in the manics, but
obtain little significance in the euphoria.
If hallucinations dominate the picture, or if the thought disturbance
advances to. unclearness and to the formation of confused delusions,
we speak of manic insanity, even though the euphoria is mixed with,
transient states of anxiety and depression.
There are also cases (very rare), where delusions and hallucinations
merge into the background, but the disturbance of thought deviates
(^}
Figs. 37 (a) and (b). Marked excitability and

/^^3^5^.^>;^^^ ^y^^^ -^^^î^^Ci;^^^^^-^^
pressure activity in a very flighty manic patient.

.

at the height of the disease from the flight of ideas. One cannot really
get in touch with the patients ; in incomprehensible ways they become
violent, externally they have a certain resemblance to excited cata-
tonics but all schizophrenic signs are absent, while the thought dis-
turbance cannot yet be characterized.
Melancholia. The depressive phase colors all experiences pain-
fully; often anxiety is added (sometimes in the form of prcBCordial
anxiety) however, the patients like to complain that they have no
;
emotion; everything seems colorless, and strange. "Colorless" also

Fig. 38. Facial expression of a melancholic. Position of the head and the
glance are lowered. The furrowed skin of the forehead is drawn more strongly
than ordinary.
often refers to perceptions, but the ability to distinguish colors remains

normal. The mimic expression is painful, desperate, anxious usually
with very little mobility; but as the conceptual content changes just
a little, one cannot speak of the "rigidity" of the affects as in schizo-
phrenia. In more severe cases the mimic secretion of tears invariably
fails to function; the patients distort the face, sob, all just as in
crying, but the eyes remain dry.
A particularly noticeable mimic sign of depression generally orig-
inates when main fold of the upper lid at the edges of its inner
the
third is contracted upward and a little backwards, so that the arch is
there changed to an angle (Veraguth)
The association of ideas is retarded." Thinking becomes slow

and hiborious to the patients; it revolves monotonously about their
misfortune^ "I think but do not get anywhere. I busy myself all the
time with something and torture myself because I cannot progress"
(Wernicke) But to the extent that the affect does not cut off certain
.
ideas, the melancholic patients can more readily get a proper view of
the more complicated relations than can the manics, when in milder
cases a certain objective interest induces them to do so. All psychical
activities are retarded. In more severe cases even retardation of
sensory perception can be demonstrated. As to content, all thoughts
are made difficult that do not harmonize with the psychic pain, so
that it comes to a pretty complete monideism.
Fig. 39.Veraguth's fold of the Fig. 40. Normal fold of the upper
upper lid in depression. lid.
Apperception also is less defective than in the manic. Melancholies

do not make mistakes in reading. To be sure, the threshold values
in apperception tests seem, according to Kraepelin, to be heightened.
Orientation is good except in the dreamlike cases into which
melancholias seem to merge more frequently than the manias.
Attention remains concentrated on the imagined misfortune; dis-
tractibility is difficult or impossible; even within the melancholic
idea, attention moves with difficulty; it does not pass readily from
one topic to another.
The centrifugal junctions are very seriously impaired. Irresolution
may grow to an unbelievable extent; a patient may want to change
her place at the table, lift up the chair, and then require half an hour
to decide whether and where she should place it.
Movements become trjang, slow, and weak. The limbs are as
heavy as "lead." Movements require just as much exertion as does
thinking.
"" See p. 74.


More frequently than in mania one observes symptoms
as accessory
delusions and hallucinations (of sight and hearing). The devil appears
at the window, makes faces at the patients. They hear themselves
condemned, they hear the scaffold erected on which they are to be
executed, and their relatives crying who must suffer on their account,
or starve or otherwise perish miserably.
But the delusions especially are never absent in a pronounced
case and always as delusions of economic, bodily, and spiritual ruin.
The patients think that they became poor, and it does no good to
show them their valuables or their balance in the bank; that has no
significance for them. Debts are there anyway, or demands are to
be expected that will wipe out everything. The patients have a
severe, incurable disease acquired through sin, naturally not a melan-
cholia. This delusion is supported by feelings of uneasiness in the
digestive tract. The convulsive contraction of the throat connected
with the depression and difficulties in swallowing prove to them
that there is a closing of the oesophagus, inactivity of the digestive
tract, and a number of other severe disturbances. The patients have
sinned in a dreadful manner; even the Grace of Christ cannot save
them; they have perpetrated especially the sin against the Holy
Ghost which can never be forgiven. "Even when I drink a little cold
water, it is stolen and I have eaten and drunk so much." They
involuntarily examine their whole life to find such crimes; they
transform slight mistakes or even entirely innocent acts into the
greatest sins. In the form of delusions of reference they sometimes
attach new ideas to what goes on about them. It is their fault that
the other patients are sick, that one has died; because of them the war
broke out, because of their sins people must despise them; every one
talks about them; in this world and the next they must be punished,
usually in the most terrible way. The melancholies have deserved
their tortures in contrast with the "persecuted." In a milder melan-
cholia the feeling may appear now and then that things are not so
bad as all that; an expected punishment may appear unjust. In other
cases also there may sometimes appear, in the endlessly complicated
workings of the human psyche, a real idea of persecution, e.g. even in
healthy people but to melancholia belongs only the depressive dehi-
sions,^^'' whose variations in genesis, in diagnostic, and prognostic sig-
nificance are entirely different from the katathymic delusion of
persecution.
Not at all rare are compulsive fears, transitory or lasting through-
out the entire phase, e.g. doing some harm to the loved one, or com-
"'Seep. 92.
pulsive thoughts, often of a coprolalic or sacrilegious nature. Unjusti-

fiable self-reproaches may assume a compulsive form before belief
in their correctness comes in and transforms them into delusions.
Among the other accessory symptoms the nervous ones should be
mentioned again which, however, in connection with anxiety, the
tendency to ideas concerning diseases, and the painful coloring of all
experiences take on a far greater significance than in mania; the
patients often complain chiefly about all sorts of weaknesses, black
spots before the eyes, roaring in the ears, headache and other
parasthesias. The beginning of the disease often gives the impression
of "Neurasthenia" (as do the mild forms during the entire course.)
Passing hysteriform syndromes also occur, e.g. fainting spells, attacks
of dizziness, and crying spells.
Their behavior corresponds to the disease. In certain relatively

milder cases, the patients try by mechanical, incessant work to keep
away the anguish and probably at the same time make up for their
supposed derelictions. But usually the ability to work declines rapidly,
which, in turn, naturally increases the patients' pain. Even in mod-
erately severe cases hardly any work is done. It may become too com-
plicated for the patient to get from one bed to another (Kraepelin) ;
they sit or lie about, and move only very little it may even go as far
;
as stuporous immobility. Sometimes they still reply to questions, but

hardly spontaneously. Under certain conditions they can still copy
but can no longer write a letter. In severe cases orthographic and
grammatical errors also occur. But a letter often shows the preserva-
tion of intelligence, by its correct form, and by the clear inquiries
concerning all situations even in patients with whom intellectual
contact is prevented by retardation.
Even when a decision has been put in operation, the patients are
not satisfied with it; whatever has been done, has always been just
the wrong thing.
Where anxiety predominates it often expresses itself in restless
movements such as striving to get away, or clinging to people; more
rarely in loud wailing, etc. {Melancholia agitata, activa). But in re-
gard to other actions and thinking these patients are retarded never-
theless. There may also be impulsive masturbation and, under cer-
tain conditions, attacks of excessive hunger as observed in the nervous,
are not rare accompanying manifestations of the anxiety. As Raptus
melancholicus one designates the manifestation wherein otherwise re-
tarded patients suddenly do something with great energy- only to
return to their previous external calm; but wherever I myself observed
these manifestations, it involved catatonics.
.

Speech is quiet, slow, as brief as possible, often up to complete
mutism. Only rarely does one observe an endless, monotonous whining.
In the same way the hand-writing shows in its pressure curve, weak
and greatly prolonged movements (Kraepelin)
Nearly all melancholies have suicidal impulses and would perish
if they were not guarded.
In the simple cases of melancholia siryiplex the depressive retarda-

tion dominates the picture. The patients are sad, anxious, see only
the bad side of everything, suffer from their inability to work, and
announce that they are tired of life. Here especially a mild form of
depersonalization is comparatively often noticeable in which the
patients conceive the outer world as well as their own person as some-
thing different and strange. Peculiar illusions of persecution bother
the patient (it is just as if the corridor were crooked, the light doubled,
the whole house reduced in size). They can no longer get the right
idea of their home and their relatives. Compulsive ideas, too, are
more noticeable here than in the severer forms. Delusions and espe-
cially hallucinations may be lacking in the mildest cases.
If the retardation becomes severe so that the patients speak very
little and no longer take care of themselves, the picture is then called
depressive stupor.
In the severer cases delusions are invariably present and may
stand in the foreground. At the same time the hallucinations usually
but not always increase.
The depressive attack, also, because of the increase of the hallucina-
tions or the thought disturbance, may assume a paranoid or delirious
appearance [melancholic insanity). As an illustration of a morbid
picture that would soonest deserve the name of paranoid, and neverthe-
less shows at once that it belongs to manic-depressive insanity, the
following may serve as a characteristic picture:
Stock broker, born 1847. Three near relatives melancholic. Quiet,
able, reliable.In 1889 sleeplessness, anxiety, increasing inability to
keep books. After a while distrustful; then ideas that his letters
were being taken, that poison was being given to him, and as a result
of which he no longer could see well. People wanted to drug him,
and have him endorse notes. He was said to be syphilitic; people
knew it; everything was being taken from him. Attempted suicide.
Then taken to insane asylum. A misprint in the newspaper and some
utterances of others were supposed to refer to him. "Everybody has
turned against me." Bad food was being cooked especially for him.
He complained about everything and everybody and was very ob-
trusive. The physician gave him rheumatic pains in the shoulder; he
Fig. 41 is the handwriting of the same patient who furnished the material for
37 (a) and (b), just as he mei'ged into a state of depression. Here the patient
shows a very scant productivity, and in contradistinction to his former euphoria
he now describes the classical feelings of melancholia toward the end of a manic
condition. Content full of feeling. Contrasted "^-ith his former writing mania,
there is a retardation in the movements, shown by the slanting lines.
complained, cried and whined. Hallucinations could not be proven.

Fairly rapid cure after one year. Then complete health. He improved
his business.In 1898, after an operation on his son, he was excessively
concerned, anxious, sleepless; melancholic ideas of povertj' which.
however, were soon entirely supplanted by delusions of persecution.
The leastand the greatest occurrences indicated that he was being
persecuted and that his life was in danger. He had to be answerable
for everybody that did anything for him. On the whole he considered
himself innocent, and only rarely had a melancholic idea of sinfulness.
This time he saw ''something horrible" on the floor, because of which
he became afraid and violent. He thought that the physician injected
poison into him with the stethoscope. On his birthday he awaited
death; fear of a "nameless misfortune." His surroundings changed into
animals that threatened him (but besides this there was still a certain
understanding of what was real and possible). Then again he refers
everything to himself. He is being persecuted, made fun of, is having
all sorts of things put into his food. The pictures on the wall have
a reference to him. With these one can put ideas into his head.
This
attack also lasted a year. Later for several years following, there
was a plain hypomanic condition with unimpaired ability to work and
clear insight. In 1915, again an entirely similar attack in which the
patient died.
Mixed States. The three cardinal symptoms of mania and
A.
depression, exalted and depressed mood, flight of ideas and mental
retardation, pressure activity and inhibition of the will, represent three
pairs of contrasts. The corresponding functions of affectivity, of
thought process, and of centrifugality changed
are, as a rule, similarly
in the disease as shown in types so far presented, and as they are in
their minor development in the normal. But besides the positive fluctu-
ations in the one field there may be negative ones in the other, and
what is more they may occur in all of the six possible combinations
which aside from the two main groups, melancholia and mania, result
from the mutation of the three pairs. The most important of these
mixed forms are: the depressive "anxious m/inia" (the affect is nega-
tive, while the thought process and certrifugality are positive), in
which with depressed affect combined with ideas of sin, the patients
speak and write much and complain that the thoughts come of them-
selves. In "excited depression" (affect and thought process negative,
centrifugality positive) one has sought to include the picture of mel-
,
ancholia agitata. But this is incorrect; the agitation is nothing but

the expression of anxiety and with it the other centrifugal functions
are plainly retarded. The "mania with impoverished thought" (affect
and centrifugality positive, associations negative) frequently occurs
during the decline of a severe manic stage. Outwardly the patients
seem easily moved, readily make a noise, feel good, but do not per-
ceive properly; try to speak but cannot say much and repeat them-
selves. As a transition to this there often appear in the manifestation

endless narratives of the same sort of thing, names of persons, or of
places. From the inhibition of the mental and centrifugal functions
and a positive affect, there originates the picture of a coagulated mania
("manic stupor") in which the patients, though they have a cheerful
,
expression, are immovable, unless at times at any opportunity they

unsuspectingly play a trick.
B. Another kind of mixture of positive and negative deviation may
also originate within the same psychologic function which we have
artificially limited. Within the limits of thinking retardation and
flight of ideas may occur side by side, whence originates heaviness
of the mental stream combined with sudden changes, and frequent
sound associations (as in certain stages of alcoholic effects). A mix-
ture of despair and cheerful self-contempt is designated by Kraepelin
as grim humor, "humor of the gallows." ^^^ A mixture of grandiose
ideas and depression is also said to occur in manic-depressive insanity
(the patient is persecuted by the emperor and king; he desires a
romantic death and similar things, Kraepelin). Kraepelin presents
a hand-writing curve which normally strong and yet very much
is
prolonged; this indicates high pressure with a retardation of move-

ment. Oneof my female patients covered all available pieces of paper
with writing but in a depressive manner with markedly sloping lines.
Her affect, too, was a mixture of depression and exaltation. The
pressure activity, combined with muteness, not at all rare in schizo-
phrenia, is supposed to have been noticed here also. In one female
patient I saw in two attacks a protracted pressure activity (long
walks) with the absence of a feeling of exhaustion with negative
signs of all other functions.
The mixed conditions of both forms are not rarely transitions
of the individual phases, but may also appear as independent com-
plete phases; they then constitute, even if the confusions with schizo-
phrenia are disregarded, a more unfavorable formation of the morbid
picture, run their course slowly and recur often, after they have barely
calmed down.
A part of the symptomatology is common to both phases, as has
already been shown us by the absence of coarser disturbances of per-
ception, of orientation, and of the nervous symptoms.
In the psychic field mention should again be made of the condition
of the memory which appears to be affected very little directly.
During and after the attacks, the patients recall the essentials of what
^'This is entirely different from the similarly designated mixture of aaxiety
and drinker's euphoria in Delirium tremens.

happened in the course of their duration, but there is rarely lacking
a more or less extensive transformation of the recollections. The
former manic patient can no longer imagine that he was so unpleasant,
and in good faith represents most of his conflicts as justifiable reac-
tions to unjust and awkward attacks, and often with such skill that
he even convinces others. The severer the flight of ideas was, the
fiiliii
^
^-^-^^mw^/ym

Fig. 42. Mixed condition in a debilitated case. Inconstant euphoria. Motor
retardation which crowds out the euphoric expression of the face but nevertheless
permits the patient to decorate herself with necklaces made of mountain ash
berries.
more difficult to be sure, is the orderly ekphoria of the experiences,

and for this reason also obscurities and gaps appear. It is significant
that individual manics believe after recovery, that they had really
suffered from melancholia, because- the few brief intercurrent depres-
sions and the most striking inner difficulties are remembered much
better and appear much more important than the cheerful total manic
condition. To be sure these recollections may point to many a psychic
and physical pain which we did not observe during the excitation.
There often exists in the healthy periods a hick of interest or a

any attention to the morbid processes,
positive disinclination to devote
as a result ofwhich forgetting is produced or at any rate simulated.
Melancholies, who as a whole have a somewhat better recollection
than the manics, may very easily repress very much, and often just
the most important things. This even occurs when in the course of
an attack they have definitely resolved that this time they will think
of this and that during the free period, e.g. of the relation to the
physicians. Often at the beginning of a later attack, the recollection
of an earlier one turns up so vividly that the patients feel it very
unpleasantly as a disturbing compulsion. The recollection of the
delusional forms is usually defective and greatly falsified, under
certain conditions totally lacking.
Insight into the disease is usually lacking and is never complete
during the acute phases, although in case of more frequent repetitions
the patients may themselves seek the institution as soon as they find
it necessary. The manic invariably estimates his own worth much
Frequently the patients
too highly, the melancholic infinitely too low.
have a relatively good insight of previous attacks, but not of the
actual one, which they alwaj^s consider "something very different."
In both phases the hallucinations are usually confined to sight and
hearing, and often have little vividness. The patients themselves
sometimes describe them as "manifestations." They are also not so
obtrusive as e.g. in dementia praecox.
The physical symptoms of manic depressive insanity are not im-
portant. In euphoria the turgor vitalis is naturally raised; a patient
who in a state of melancholiaa broken up individual may appear
is
twenty years younger the next day when he has merged into a manic
mood, and then present a vigorous bearing and good appearance. All
vegetative functions adapt themselves to the situation. The exalted
person usually has a good appetite and effective metabolism; sub-
manics who eat regularly and do not exhaust themselves with inces-
sant movements consequently usually gain; more severe manics, to
be sure, lose, partly also because they do not take the trouble to eat
enough, and instead use their food as material to satisfy their pressure
activity instead of their hunger. I once had an experience by way of
exception, where a manic could be saved from death only by being
forcibly kept in bed, because his heart did not keep up with his activi-
ties, so that e^'ery now and then he developed hydrops universalis.
There was no endocarditis. In melancholia the appetite fails, the
bowels are also often sluggish; as a rule there is a loss of weight;
an increase of weight, with very few exceptions, indicates recovery.
;

Pronounced increase in strength without accompanying recovery indi-
cates a different, especially a schizophrenic, foundation.
In both phases sleep is poor, often so poor that a normal person
would rapidly break down under it; the function of recuperation must
take a different course in the disease than under normal conditions.
Examinations of body temperature, of the blood, urine, and
metabolism generally have as yet yielded no regular findings. Notice-
ably often one finds sugar in the urine during the attacks.
Pulse and respiration correspond approximately to what one ex-
pects from emotional excitations and depressions of normal persons.
Menstruation often disappears, to -reappear toward the end of the
attack.
The reflexes are sometimes increased; in the manic state they are
said to be rapid, in the melancholic slower. Manic "analgesia" is
the result of changed attention.^^^

The intervals. Between the attacks most patients show so little
that is pathologic that one speaks of "normal intervals." Never-

theless there is seen in many, especially when the disease has existed
a long time, a distinct lability of the emotional condition, partly as
a reaction to external conditions with irritability and exaggerated
excursions in the direction of euphoria as well as depression, partly,
however, as passing fluctuations from within, which Kraepelin con-
siders as rudimentary attacks. In individual cases only a very small
percentage of all manic depressives
this goes so far that the patients
lose their ability for social functioning; they are no longer capable
of adapting themselves sufiiciently to others and lack all stamina for
independent work. In contrast to this the ordinary "intelligence tests"
do not show any evident decline. In the periodic manics there fre-
quently develops in the intervals a protracted mildly manic tempera-
ment; in those patients with mainly or exclusively melancholic phases
there develops a protracted depressive mood of minor grade. Of these
types there are all transitions to those who from youth onward appear
mildly manic or melancholic and then are preferably afflicted with
phases having similar signs.
Course. In the majority of the cases the disease becomes manifest
through the first attack between fifteen and thirty, but at times may
first show itself in the eighties. Individual cases go back to childhood
but every child which in youth seemed a little cyclothymic does not
by any means later become manic-depressive; the anomaly may lose
itself.
In general the attacks repeat themselves at varying intervals; im-

"See p. 56.
mediately after the expiration of one, another may appear, or decades

may elapse from one to another. Naturally under these conditions it
may also happen that in the course of a single life only one appears.
But there are patients with whom for many years one can count
on a more or less regular succession. If the intervals are about equal
and not too long and the attacks of the same kind, one speaks of
periodic mania and periodic melancholia; as cyclic (or circular)
insanity are designated the types in which mania and melancholia with
or without free intervals follow in regular succession.
For the quality of the attacks also we do not know any rule. The
longer one can oversee the patient's life, the more rarely one finds
series which are made up of the same kind of attacks. On the whole
melancholia increases with age, while mania decreases. Severe manic
attacks are likely to occur in the same patients with severe melan-
cholic attacks, while submanias and submelancholias correspond in
turn. For a long time many patients have attacks that resemble one
another very exactly; one even speaks of a photographic exactness of
the repetition. One of my ''paranoids" each time took up again the
delusions formed in an earlier attack to develop them further (in-
ventor, reformer) .
The single attack, aside from the mixed conditions
of the transition, usually keeps itself within the same category. But
in severer attacks with otherwise clear states in respect to both phases,
confusion states lasting fifteen minutes or hours are not entirely rare,
in which on the one hand, the patients whine senselessly, throw them-
selves on the ground, take no consideration of decency, and are inac-
cessible to any advice, and on the other hand, senselessly rage and
struggle. According to Kraepelin patients with mere depression are
more frequent; those with mere manias are the rarest.
The individual attacks usually last many months, a half year to
a year, the melancholic probably on the average somewhat longer
than the manic; upward deviations to several years are frequent, up
to ten or more years very rare. By way of rare exception, individual
patients have a tendency to complete their attacks in one or two wrecks.
Prodromic symptoms frequently take the form of general discomfort
which is taken to be neurasthenic, and strangely enough not rarely in
the forms of neuralgias which may have all the marks of a definite
nerve inflammation, e.g. sciatica or intercostal neuralgia. A patient of
Schuele hallucinated a gray bird every time at the beginning of the
attack. Mania is preceded sometimes but not always by a really de-
pressive introductory stage. The ascent is gradual, in severe attacks
not very rarely in two periods, as after about two or three weeks'
duration a remission occurs, which, however, is soon followed again
by a severe aggravation. Then the disease usually remains at its
height for a long time. Recovery sets in gradually and with fluctua-
tions, in melancholias frequently so; better days appear, which after
a while recur more frequently and show a more evident decrease of the
symptoms. During the falling off of the mania the inhibitions then
taking place simulate a "dementia" for the inexperienced. Not so
rarely the character takes on an unpleasant nagging. After the manic
attack there often follows a more or less severe depressive after-stage,
or at least a feeling of exhaustion. After melancholic phases the pa-
tients often feel "better than ever," are more active and pleasant
than before, and that not only for months, but even for years. The
rare sudden fluctuations occur especially in cyclic cases, in which the
patient may change the phase from one day to the other. But transi-
tions from, and toward the normal conditions, may at times also appear
suddenly by way of exception.
Concerning the general prognosis little can be said as yet. The
individual case recovers. Very rarely does a patient stay over in the
asylum, because the intervals become so brief that a discharge cannot
be considered. Every now and then a case makes his home in the
hospital and remains there willingly even when the intervals are
longer. Longer series of attacks seem to have a tendency to decrease
the intervals with age. But in general the admissions decrease quickly
in the forties, in spite of a slight increase between 45 and 50, and
after the period of involution we see only a few of our regular customers
from early manhood. Therefore many later remain free at least from
more severe attacks.
The quality of the attacks sometimes seems somewhat more severe
in old age; the manias are less strong, the melancholias rather con-
fused; probably the delusional forms also increase a little.
During 'the acute phase death may occur, among melancholies

chiefly as the result of suicide, otherwise from intercurrent diseases;
some suicides take their families with them ("family murder"), in
order to save them too from misery. Manics die at times from ex-
haustion or from injuries which they will not permit to be treated.
Manic-depressives have a certain tendency to suffer relatively
early from arteriosclerosis, or other brain atrophy.
Protracted Displacing of Mood. To manic-depressive insanity be-
long the high and low spirits, which on the one hand do not last
long, and on the other do not attain the degree of a morbid mood.
For the latter reason they rarely come under psychiatric observation
in spite of their frequency; nevertheless now and then a fluctuation
of the mood rising to a pathological degree demonstrates the con-
nection with the entire group, which moreover is made closer by

heredity. The following forms can be distinguished:
L Constitutional ill-temper or depressive disposition ("melancholic
mood"), a protracted dark emotional coloration of all life experiences,
difficulty in making resolutions ; lack of self-confidence.
2. Constitutional excitement or manic disposition ("manic mood").
The manic temperatment of such people disposes to overhasty acts
and to a thoughtless manner of living in general, when it is not
restrained by a particularly sound understanding and a particularly
good morality. For that reason we find here on the one hand snobbish,
inconsiderate, quarrelsome and cranky ne'er-do-wells, who have no
staying powers in their transactions, but on the other hand "sunny
dispositions," and people endowed with great ability, amounting
sometimes to genius, and not rarely gifted with artistic ability who
possess a tireless energy. Such a man, e.g. was the founder of
"Physiognomies," Lavater.
3. The irritable mood.
4. Cyclothymics, in whom periods of energetic euphoria alternate
with despondent impotence. Among these too are found artists and
other people who do great things. Moebius has given good reasons for
counting Goethe with these. Whether H. von Kleist should be called
manic-depressive or cyclothymic is arbitrary.
5. The constitutional disposition may also change, especially
around the time of puberty. David Hess was depressive as a boy,
then said to himself one time: "Now I am no longer melancholic,"
and remained until death in a manic mood; his sister, from youth up,
was always "like quicksilver." Lavater too wâs sensitive in youth,
"bashful," as was a famous still living scholar with a manic mood.
A woman up to about her twentieth year seemed noticeably cheer-
ful, lively in the pleasant sense, then for a time mildly depressive.
Her membership in the manic-depressive group was proven by a

melancholia lasting several years which began at forty-one, after
which for ten years she was lively and very energetic, bore hea^y
blows of fate admirably, to be melancholic again at 54 for three
years.
As '^milder forms" periodic conditions are also to be mentioned,
which take a course under the picture of neurasthenias or stomach
neuroses or headache.
Conception. Manic-depressive insanity is a lasting anomaly that
produces fluctuations in the sense of mania and melancholia and also

readily shows itself in other ways as a lability of the sensibilities, or
in the form of habituail shiftings of the mood. Everything that goes
with this is shown by the examination of the family disposition which
points to an equivalence of all the outlined disease pictures.^^**
So far everything is readily comprehensible ; but there are certainly

moods of a different origin which we cannot as yet distinguish as such
from the manic-depressive. Therefore in regard to the differentiation
we are not altogether certain where one of these other causes might
cooperate, and, on the other hand, this fact must make us hesitate to
endeavor to explain the attacks merely on the basis of predisposition.
Some of these moods are undoubtedly purely psychogenic others have ;
a physical foundation, as in paretic or senile processes, in dementia

praecox, and in disturbances of the inner secretion (Basedow manias
and melancholias). Physical diseases, especially cardiac and vascular
disturbances, produce depressions; incipient fever, chemical remedies
like alcohol and tuberculin generate conditions, which have at least a
great resemblance to mania. Now is it necessary for the appearance
of such effects that there be always or at least in many cases a manic-
depressive disposition? Is cerebral atrophy often or always or never
the sole cause of the accompanying depression in senile forms? Are the
^^^
cyclic forms of schizophrenia all mixed forms of the two diseases?
We cannot answer all these questions.^"
If all along we have placed the affective fluctuations in the fore-
ground, it was with the understanding that they are only the most
conspicuous expression of the more general psychic disturbance. For

it is true that the more important symptoms such as flight of ideas,
pressure activity, associative and centrifugal inhibitions, which alone,

besides the actual mood, are usually tangible, are indicated in every
strong affect and may, therefore, be conceived as exaggerations of the
"emotional effect." But opposed to this is the fact that the three
symptom groups need not at all correspond quantitatively to one
another even in the ordinary cases, thus the centrifugal retardation,
e.g. even with painful mood that remains the same, may oscillate not
only from one case to another, but also in the same patient. It is, for
example, usually relatively more severe in young people than in cases
of the involutional period; but above all the mixed states prove that
the derivation of the entire picture from an affective fluctuation does
not tally at all, or only to a slight degree. Then, too, especially in the
thought disturbance many symptoms transcend the emotional effect,
"" Compare the relation to the syntony of normals, p. 174.

"^ There are certain forms which symptomatologically give the impression
of manic-depressive-schizophrenic mixed forms, but are a unity at least in the
family disposition.
^ Concerning the psychogenic release of true manic-depressive attacks, see
pp. 132-489.
which on closer inspection are more frequent in the apparently simple

cases also than would appear from the descriptions; only one cannot
as yet grasp and describe them properly. Complaints about the
obtrusive crowding up of a mass of ideas, the interference with the
arbitrary direction of thought, the obscurities that belong to the flight
of ideas and which in individual cases with a mere indication of flight
of ideas or retardation may go as far as confusion and dream-like

states, the hallucinatoryand paranoid symptom complexes, paresthe-
sias and "neuralgias," all
of these prove a positive number of dis-
turbances which must be of the greatest importance for the explana-
tion, but which as yet have eluded our comprehension. Behind
the customary expressions, dispositions, exhaustibility, irritability,
inner secretion, there lies concealed in manic-depressive insanity very
little, or nothing at all, that is matter of fact or even intelligently
connected.
Extent. Kraepelin's idea of manic-depressive insanity is pretty well
circumscribed. The transitions of the various forms among them-
selves and especially in the same patient, and the hereditary conditions
prove the homogeneity of all the different pictures. The group can-
not be sharply delimited from many mere psychogenic distempers in
psychopaths, and from the melancholias not to be included as yet. A
natural boundary also probably does not exist between the habitually
moody and the ''psychopathic personalities," especially between our
irritable cases and the excitable among the psychopaths.
Of the conceptions of other classifications several correspond to
individual forms of manic-depressive insanity or they disagree with
it. The "mania" and "melancholia" of German psychiatry naturally
belong to our disease, but all diseases with this name of non-German
authors do not; they include a large part of the excited and depressive
forms of other psychoses also, especially of schizophrenia. Probably
everything designated as periodic neurasthenia, recurrent dyspepsia,
etc., also belongs entirely to manic-depressive insanity; also attacks
of hypochondria, and Friedmann's neurasthenic melancholias. The
"acute" and the "periodic paranoia" correspond in part with our manic
and depressive delusional forms, for the greater part, to be sure, with
schizophrenic hallucinoses, similarly the majority of the amentia cases
of the classifications other than Kraepelin's. Some of the litigants are
manic-depressive or cyclothymic; if one has a good anamnesis, they
are easily recognized; as distinguished from the paranoid litigants
they have times in which they keep themselves very quiet, and even
see the senselessness of their previous conduct and regret it also the de- ;
lusional system does not remain homogeneously centered. A part of

the patients coming to the physician because of compulsive thoughts
are depressive types.
"Melancholia" requires a special consideration. It is self-evident
that very many of these afflictions fit in the above class. But, as was
indicated, there are other depressions and it does not seem reasonable
to bunch all the appar:ently independent depressions of the period of
involution and class them with manic-depressive insanity. Formerly
Kraepelin actually endowed the melancholia of the period of involution
with a nosological independence as melancholia katexochen which,
however, can no longer be sustained in the differentiation of that time.
But the reasons for the separation were nevertheless very weighty.
These forms have in great part a much more protracted course. They
grow very slowly, often for one or two years, readily remain in their
height for several years and again require a long time to decline. The
retardation is frequently concealed by a great restlessness; really
agitated forms are frequent even though probably rarer than in the
senile melancholias. Then they regress much less than the others.
Single attacks are very common in these cases. To be sure^ if one
wishes, one can conceive of the thing in this way; that with increasing
age and most especially in the period of involution, the disposition for
depressive attacks and for agitated and slowly developing forms in-
creases, so that with a slight predisposition an attack occurs merely
at this age and usually in the described form. But one often gets the
impression that something else is involved; this is true also in the so-
called "climacterium" virile," a depression common to men, which
runs its course in this form but is usually mild, which appears at the
end of the fifties, even at the beginning of the sixties, rarely makes
an asylum necessary, but nevertheless plainly reduces the joy of
living and the ability to work, and usually presages another disease
(arteriosclerosis!), but disappears in two or three years without
leaving a sign. As long as we do not know the "nature" of the affective
psychoses, only hereditary investigations have any prospect of throwing
light on the subject. At present this separation is just as impossible,
as an inner grouping of the cases which undoubtedly belong together
in the wider classification.
Purely psychogenic depressions which occur in psychopaths who
are not manic depressive and attain the height of a disease are very
rare.^^^
As a definite cause of manic-depressive insanity we know only the
inherited disposition where the different forms of the disease may sub-
stitute one another. The one member of the family is cyclothymic,
"^ See p. 537.
the other periodically melancholic, the third circular, etc. But in

some families one or the other of the two phases predominates. I
knew a family in which for five generations quite a number of members
had committed suicide at the time of involution. One can take for
granted that about 80% of all these patients are tainted, if the con-
ception of "taint" is not too limited, and in large part in such a way
that equivalent anomalies are found in other members of the family.
The endowments of the patients are often noticeably good, espe-
cially along artistic lines also, which is probably connected with their
sensitiveness. One also finds more manic-depressives in the upper
classes than in the lower.
According to sex about 70% of the patients are women.
Kraepelin found among the Javanese little tendency to depression,
instead more to excitation. In the large insane asylums of Costa Rioa
with Indian inmates and in Jamaica with colored inmates, one does
not count at all on suicide, although I was told in both places that
many years ago one had occurred. The Jewish race is evidently
strongly disposed to manic-depressive insanity. Within that race also

the frequency entirely aside from changing delimitations varies
greatly, in German Switzerland it is very small, in middle Germany-
^^*
it is higher.
It is also supposed that brain lesions generate the disease, especially
the delusional forms, which we still have to include in manic-depressive
insanity. But up to the winter of 1919-1920 we know of no injuries
to the brain incurred during the war that could have led to manic-
depressive manifestations.
Individual attacks in large part come from within. War did not
seem to release them. But one cannot doubt that now and then (I
estimate about 10%) they can be released psychically; thus in a
woman good family, who probably in a moody state married an
of
insignificant man, and during many years always had a manic attack
every time the attempt was made to have her join his family until
the husband died.
Manias also occur at times after the puerperium in women who
otherwise, as far as their lives can be investigated, have no attacks;
then as menstrual insanity where they last only from eight to four-
teen days. In one case of my observation an attack did not occur
at every menstruation but the attack never came without menstruation.
^Ît is disproportionately high among the Jewish admissions of the Man-
hattan State Hospital, N. Y., which contains a rather mixed element of Jews.
Cf. Brill & Karpas, Insanity Among Jews, N. Y. Medical Journal. Oct. 3. 1914.
Also Kirby; Race and Psychopathology, N. Y. State Hospital Bulletin, March
1909.
Milder depressions are not rare in pregnancy but as a rule disappear
with the birth.
make a diagnosis from a symptomatic investi-
It is often possible to
gation one obtains a good account of preceeding attacks with healthy-
if
intervals. But if the anamnesis is lacking or if it is a case of a first

attack, then manic-depressive insanity can be recognized only by the
elimination of other diseases. There are no specific signs of the affect
psychoses; everything occurring in manic-depressive insanity can also
be seen in other diseases. If, however, in spite of exact observation
no specific symptoms of another psychosis is found in such "mood,"
one may decide on manic-depressive insanity. But since a catatonia

or a paresis may
run a course for some time without distinct specific
signs, one must not, at least in the first week, decide with certainty on
manic-depressive insanity. Signs, which symptomatologically should
be called catatonic, are said to occur here also; but at all events this
is rare.
Special difl5culties are presented by the paranoid and delusional

forms; there only protracted and careful observation will make it
possible to drop the suspicion of dementia prsecox. On the other hand,
differentiation from paranoia, for which the form was not so rarely
mistaken, is made easy by the evidence of the depression.
usually
Cases of dementia praecox are often mistaken for mixed forms.
Only a more prolonged and exact observation with a weighing of all the
circumstances, and sometimes a good anamnesis, will guard against
this error.When in doubt one should remember that the pronounced
mixed forms, especially the manic stupors also, are much rarer than
similar schizophrenic conditions.
Incipient paresis can be differentiated by the physical signs and
the senselessness of the delusions and by the examination of the spinal
fluid. But hypochondriacal ideas, even in case of a good intelligence,
can well strike the physician as somewhat senseless, since in such
matters the healthy person also often has very peculiar notions.
Manic excitements can be differentiated from the epileptic even
in a brief examination by the flight of ideas which does not occur in
epilepsy, and by the absence of the signs of epilepsy, especially the
slow mental process, the obscurity and peculiarities of speech.
Some hysteric symptoms may occur in manic-depressive attacks,
especially when they are also present in the intervals. Pronounced
and stubborn but isolated hysteriform symptoms point with prob-
ability to a complication with organic or schizophrenic diseases.
Manias that belong to hysteria probably do not exist; but it is possible
that there are such depressions.
A differential diagnosis from psychogenic depressions is symp-

tomatologically not possible as yet. But on weighing all the circum-
stances, especially the family anamnesis also, one will, especially
after the recovery make the diagnosis with considerably certainty.
Treatment. The predisposition might be eradicated by forbidding
the begetting of children in manic-depressive families. It is a question
whether this would be wise because a large part of these families
maintain themselves in spite of all and even do distinguished things.
The seriously sick naturally should not marry, not even in the free
intervals; at all events I would not like to advise anybody to select
a manic-depressive mate, as the difficulties for the healthy partner are
often greater than for the one afflicted. But I must state that in spite
of this, things go well in individual cases; the able and pleasant afflicted
partners, when necessary now and then, take treatment in an insane
asylum, and in the intervals may be excellent companions.
Also for the prevention of the individual attack not rnuch can
be done, because it usually comes about without external occasion.
Nevertheless the avoidance of excitements and excesses of all kinds
is good in other respects also, if it can be achieved.
With pronounced manics nothing can be done except to send them

to a hospital. There the attack most easily runs its course in spite
of all irritations because of the confinement. As far as possible irri-
tants should be kept away; isolation, which still gives the patient a
chance to entertain himself somehow with trifles, is the therapy which
should be applied whenever possible. As distinguished from schizo-
phrenia a ^'degeneration" resulting from isolation is not to he feared.
If it is not feasible, then the supervised continuous bath is the best
place for the patient to stay. Occasionally artificial feeding may be
necessary.
The milder cases which one cannot resolve to send to a hospital
are a trial. They have the tendency to ruin their fortune, their honor,
their health
a girl of good family, in six attacks only came to the

hospital after she was pregnant they bother others, enter into litiga-
tions, and through sexual relations, engagements, etc., make also others
unhappy. Under certain conditions a legal guardianship, where that
is possible, can prevent much harm. But the guardian has a difiicult
task and his most effective intervention probably is to bring the
patient to an asylum. In addition there are rare cases who particu-
larly in the submanic stage, in spite of difficulties with the environment,
have made a fortune by their initiative and inventions. But in general
it is very risky to let submanics go their way they always seek more
;
excitements and just these should be avoided.


For melancholia also supervision in a closed hospital is the right
thing. On the outside many from suicide, and

of the patients perish
even from starvation. But just in such depressions without other diffi-
culties the family physician will not always be able to disregard the
objections of the patient and the family to institutional treatment.
But he should only assume the responsibility if the external condi-
tions also warrant Against the danger of suicide strict supervision
it.
should be prescribed; but it does no good merely to say this generally,

even though it be done most impressively. It must be made plain to
the relatives that at least two attendants must relieve one another,
that both attendant and patient, e.g. will go to the toilet and that at
such times also supervision is to be carried on; because if the patient
wants to take his life, he uses just those occasions of which one later
says: "But it was only for a moment." Usually the windows must
be secured, and when possible the patient should live on the ground
floor. In the milder cases an orderly who sleeps very lightly may
sleep beside the patient, perhaps placing the bed so that the patient
can get away only over him. Especially dangerous is the period of
convalescence when the impulse to suicide is still present, at least in
the form of attacks, and the patient's energy is no longer very inhibited,
while the vigilance of supervision usually lets up. Where a continuous
supervision is not found necessary the physician must see the patient
more or less often, usually daily, according to the fluctuations, to
inform himself minutely from those about him concerning his condi-
tion in order to be able to intervene at the right time.
Supervision is made much easier by protracted bed treatment,
which is also indicated for other reasons in severe cases, but which
becomes a torture in milder cases who have the ability and feel the
necessity of moving about in the open and even busying them-
selves.
In anxiety melancholias one can make the attempt to shorten the
attack with an opium cure: opium or now pantopon in increasing doses
within three or four weeks up to 1.0 Opium (0.2 Pantopon), or a little
more; from one to two weeks after this high dose has been reached,
one should go down just as slowly whether or not the attack has
improved. Because if one has not accomplished anything then, the
remedy is no longer effective but may make an opium addict of the
patient.
Against sleeplessness hypnotics (not opiates) will have to be given
now and then. The patient who usually does not want to eat, must
be fed sufficiently, perhaps by the tube. Against the frequent con-
stipation mild laxatives are to be used and what is more important
to prescribe daily attempts, exactly regulated as to time, to go to

the toilet.
''Distraction" can attain some mitigation only in the mildest cases;

they usually do harm; the most beautiful music can have no good
influence if the patient reacts to it with mental pain. Also all other
kinds of complicated conversations are usually harmful, even if they
can divert for a minute, because afterwards a reaction usually sets in.
Here a careful testing is the right thing. The effect is best attained
by work which does not tax the patient mentally or demand any
decision from him. In general it is very important to relieve the patient
of all decisions, even of those that are simple, and involve trifles,
until an extensive improvement has taken place.
In pregnancy melancholias the question of abortion is often put.
There are individual cases where the measure has had good results."'
In contrast with the schizophrenias early discharge from the asylum
is to be guarded against. Many of the patients get worse outside;
even in the asylums one has the experience that they do worse if they
are placed too early in a better ward.
XII. PSYCHOPATHIC FORMS OF REACTION (SITUATION

PSYCHOSES)
In case of any kind of disturbances within the psyche the affects
also must function differently than otherwise and may then generate
morbid syndromes.^^ Congenital anomalies, brain injuries, brain
processes of all kinds, disturbances of nutrition, toxins, infections, and
finally chronic emotional effects themselves constitute in their multi-
colored manifoldness and in the most different combinations the founda-
tion on which the abnormal reactions occur. Where definite processes,
like the schizophrenic, or coarser organic brain changes, be at the base,
the reactive syndromes are classed with the symptomatology of these
diseases from which they usually derive specific peculiarities (schizo-
phrenic delusions, although originated in the same way as the para-
noid, differ from the latter; schizophrenic twilight states from the
hysteric, etc.), where the abnormal reaction is based on a congenital
disposition, the attempt has been made to distinguish it
often in

connection with the disposition as a special "disease" [neuroses,
paranoia) In such cases it is usually the abnormal domination of
the affect, i.e. its excessive influence on the selection of the associations,
sometimes also only the relative weakness of the logical faculties,
^ Comp., however, p. 225.
''
Comp. p. 126.
perhaps also of the affective inhibition (e.g. moral) which make the
origin of morbid symptoms possible. But qualitative deviations of the
affects as well as the intelligence, special sensitiveness in a particular
direction, crankiness in thinking, etc., may also be the essential basis
of the abnormal reaction form. However, the affectivity with its
unlimited possibilities of variation is always the decisive factor while
the narrowly confined intellectual functions are overwhelmed or only
participate in a secondary role.
Most syndromes can best be kept distinct by means of the under-
lying mechanisms. Many are simply exaggerated affective effects:
attacks of rage (e.g. Prisoner outbursts) , attacks of screaming, stupor,
momentary confusions, and fright neurosis. Here the easily aroused
dominating affectivity or inadequate ability to deliberate is the main
condition (Primitive race, "the nervous," oligophrenics, schizophrenics,
epileptics). It is a case of "primitive reactions" (Kretschmer) But.
also in those not otherwise disposed to such reactions, some complex

among other things may generate a particular sensitiveness: unre-
quited love, incessant "pin pricks," unworthy attitude, etc. More
rarely ambivalence is the cause; thus in excessive anxiety for certain
people, or in too violent or too protracted grief for some lost relative,
where usually the unconscious feeling of some advantage derived from
the loss causes the exaggeration by way of a sort of feeling of sin. As
a rule patients of the latter sort are persons of more sensitive natures.
Another mechanism is the false connection to which among other
things many sexual abnormalities are to be ascribed: A pupil in a
classroom has his attention called to onanism by another pupil and
at once makes an attempt. The teacher sneaks up and pulls him by
the ear. At this moment the orgasm takes place and the result is that
the patient can never obtain sexual satisfaction unless he himself or
his beloved holds his ear (Aschaffenburg) . In an analogous way the
various form of fetichism originate, naturally only in a psychopathic
disposition, probably in connection with weak sexuality. An eleven
year old patient of Frank suffered since his fifth year from inconti-
nenta alvi, especially in the forenoon at half past ten. Psychoanaylsis
revealed that six years ago at this hour, having to go to the toilet, he
went to his mother where hot fat was sprayed on his

in the kitchen,
chest. In his fright he defecated in his clothes. Cure resulted from
this explanation.
Other chance associations produce e.g. headache,
always after some particular occurrence, because the first time head-
ache appeared after it. This kind of connection may originate, espe-
cially in children, even without the essential cooperation of an affect;
then it is merely a case of habituation or association reflexes.
Unbearable situations or those wished to be otherwise may be

delusionally transformed by the disease (delusional reaction), or cir-
cumvented in reality {"Flight into disease"). The latter procedure
in case ofan existing schizophrenic process sometimes makes the disease
manifest, but above all it leads to the neuroses, which is accomplished
by the fact that the unbearable ideas with their affect are split off
from consciousness and "repressed" into the unconscious, where they
make themselves noticeable by supplementing morbid symptoms.
Delusional Reaction: In an hysterical or schizophrenic twilight
state the patient hallucinatorily marries the lost lover; in delmsicms of
grandeur unrealizable wishes are gratified. In paranoia and paranoid
demsions of persecution the cause of one's own failure is projected into
the environment, the blame is taken from the ego and besides the
latter is relatively elevated by means of ascribing malice to the other

people. In litigiousness one seeks, on the one hand, to fulfill wishes
that in reality can be fulfilled with difficulty or not at all, and, on the
other hand, one conceals the opposing rights of others and the diflB-
culties of achieving one's own demands; one also overvalues one's own
rights and, along with this, the importance of oneself and thus justi-
fies one's own sensitiveness and joy in oppressing others. In the
litigious delusion of paranoia, of the paranoid, of the submanic attack,
this affective effect extends to the complete falsification of logic; the
kind of reaction, the "choice of the disease," depends here on the
psychic constitution of the patient and very little or not at all on
the occasion.
Difficulties of intercourse with the environment lead to delusions
of persecution in those who are hard of hearing.^"
A special attitude is taken by the mechanism of induced insanity:
the taking over of a patient's delusions by a previously healthy person
as a result of persuasion and especially suggestion. But there too an
affective predisposition must be assumed, which permits the acceptance
of delusions having a definite direction.
By means of flight into the disease one achieves definite aims
through the disease; by an attack of rage one achieves a yielding; by a
fainting spell, a new hat; and by the more protracted disease one gets
a pleasant sojourn in a sanatorium. By means of all these one can at
the same time compel consideration, secure care and tenderness, obtain
power over others who have to adjust themselves to the disease, extort
an allowance, evade tasks from the simple household duties up to the
terrors of the trenches. But above all one circumvents inner diffi-
culties; one keeps off self-reproaches from consciousness; by means
^' See p. 533.
of a symptom one identifies oneself with the beloved, or represents
symbolically the union with the beloved who does not care for the
patient.
Such external aims of the neurosis are very simple; the inner pur-
pose, the fictitious accounting to oneself is often so complicated that we
cannot go into details here. Only this should be mentioned, that
naturally the neurosis is usually a poor solution from the subjective
point of view also, as is shown by the fact that neurotics themselves
condemn the evasion of difficulties by this means, because they do
not admit the purpose of the device either to themselves or to others.
Even the attack of rage which under these circumstances represents
a primitive reaction, sensible in principle, often overshoots the mark
so much that becomes most unpleasant for the patient. In order to
it
get the hat, one must have a real fainting spell; to be excused from
work, one has unpleasant symptoms; the pensioned neurasthenic has
to renounce all joy of living. Whoever becomes a thief out of revenge
against the father or commits arson because of an unbearable situation,
gets into jail; whoever achieves the companionship of the beloved
symbolically is as little satisfied as the hungry dreamer who thinks
he eats, and whoever satisfies his ambivalent feelings by imagining
a sexual attack, which, though it arouses sexuality at the same time
causes disgust, only gets hysterical vomiting out of it.
When we speak of flights into disease, as a sort of purpose of the
neuroses, this should be understood with some reservation. A more
primitive reaction passes away and has no subsequent significance.
But it becomes a neurotic symptom, difficult to combat, if it is released
for definite purposes. If physical, purely reactive symptoms, like
paralysis of the vocal chords or the leg, trembling when in danger,
diarrhoea or fainting from fright, vomiting from disgust, do not disap-
pear with the releasing affects, or when they always recur without an
adequate occasion, then there is involved something different in prin-
ciple from simple reactions; there is a positive quantity added, which
as a rule consists of some necessity for being sick. If the term ''wish"
is applied to this, it is to be understood in the widest sense. The most
decent person occasionally has an impulse to take what does not
belong to him or do something sexual that is not permissible; but it
does not enter his head to act on this. Not at all seldom the patho-
genic wishes are entirely unconscious, while in the patient's conscious-
ness the opposite impulse is not only important but solely dominant
or solely present.
The "morbid gains" are usually easily found on closer inspection.
They are plain in the war and income neuroses, in the twilight states
of commitments for examination; in "mass hysterias" or "imitative

hysterias" they are based, among other things, on the desire, on the
one hand, to be in the swim, and, on the other, to be distinguished from
the mob. In school epidemics freedom from school is a special con-
sideration, but in addition also the making oneself important and the
imitation of everything conspicuous.
Naturally there are diseases of a neurotic kind, for the origin of
which, at least in principle, an advantage is not necessary. Many
primitive reactions, the suckling who perishes from anorexia in an
unsympathetic environment, the homesick nurse-maid, the dog that
starves on his master's grave, the girl that always gets pains in the loin
when she lies in the grass after she had lain in the open during an
illegitimate birth, the false connections of the sex impulse, the fever
that appears after the injection of water when this is taken to be the

accustomed tuberculin, all these are illustrations. But in the ordinary
neuroses one always finds on close inspection an advantage from the
disease.
But there must be something besides that permits the nervous to
take refuge just in disease, while there are other means of evading
the difficulties. To be sure, it should be remarked that this evasion
lies close at hand in our super-Christian age with its petting of weak-
lings, and is particularly encouraged by many families especially in
the bringing up of children. But it is probable that still other forces
bring the hysteric to the expediency of disease ; thus many intellectual
constellations, then the experience that with his strong affective reac-
tions which at times appear even to the layman morbidly exaggerated,
he often accomplishes his purpose, and perhaps there is a certain
weakness toward the idea of disease. All of this Kohnstamm brings
together under the name of weakened "health conscience," which says
as much as a long explanation, and which therefore I wôuld not like
to dispense with, though many object to it because "hysterics are again
having some odium attached to themselves." This objection is based
on an entirely wrong conception, which one cannot sufficiently guard
against. There is not involved a defect in the sense of "morality" or
a weakness of the conscious psyche which one can make responsible
and blame, and it is a serious theoretical and still more serious practical
mistake, merely on the basis of neurotic symptoms, to reproach a
patient with not wanting to get well.
A few additional references should be made to the individual
mechanisms of the neuroses. Besides in the "neurotic excitations" we
find merely exaggerated or primitive reactions, e.g. in heart, symptoms,
paralyses of the legs, or the vocal chords, in hysterical vomiting, in
diarrhoea from fright, and in fainting spells. Hysterical twilight states
are usually to be conceived as exaggerations of the emotional effects
that make way for desired associations and exclude the undesired.
Others are repetitions of emotionally accentuated experiences, that are
undertaken, partly because they are ambivalent and have a pleasurable
component (twilight states as repetitions of sexual attacks), partly
because they are bound up associatively with definite affects. More-
over, many syndromes that come in the form of attacks are released
in accordance with the scheme of the association reflexes, whereby the
momentary necessity for the disease withdraws as a pathogenic factor;
the sight of a cap of a certain shape releases palpitation or an anxiety
attack, because the critical person wore such a cap. Any chance event
"recalls" a sexual attack, whereupon this is lived through in a more
or less caricatured form in a twilight state. Such connections may be
known to the patient, without on that account losing their reality.
'
Very elementary the simple ^'reflex enforcement" (Kretschmer)

also is :
the trembling reflex may be released under circumstances which would

not be possible in the normal. For the neurosis, as for the affect and
for suggestion, there are available many, especially physical mecha-
nisms, over which the conscious will has no influence. Many symptoms,
like nervous palpitation, fainting spells, throat spasms (globus), and
perspirations, are released by the setting in motion of preformed
mechanisms, thus also the "hysterophilic syndrome." ^^^ Certain
others, such as headache, insomnia, and impeded thinking, originate
otherwise especially easily under the influence of ideas. Hence a syn-
drome consisting of depression, sleeplessness, loss of appetite, impeded
thinking, and palpitations during all mental or physical "work" (I
purposely avoid the term "exertion") is so common in damage suits
following accidents. In a characteristic manner the craving for an in-
come determines the disease, and the fear of being without means of
support determines its finer shadings (the patient not only has a desire
for support but also the fear of having to be without work and in-
come). Other reactions must first have existed in the imagination, in

order to become capable of assuming an hysterical form. It is not easy
directly to suggest to oneself and others vomiting, diarrhoea, perspira-
tion, or palpitation, but it is quite possible if appropriate situations,
such as having eaten something disgusting, feeling heat, and of terrify-
ing situations are pictured in detail. Thus even the nervous person will
most easily get those symptoms from imagination (auto-suggestion),
that he has already experienced (pains in the back as a repetition of
earlier rheumatism), or he will utilize an existing trouble, any other-
" See p. 543.
wise insignificant deficiency in an organ (stomach!), in order to make

a disease ofit {"physical complaisance") Some physically conditioned
.
disease is (especially in the case of children) afterwards continued

psychically, most frequently perhaps whooping cough, chorea, and
blephorospasms. Instead of being "utilized" directly, a predisposition
may also be strengthened or actually made by some added factor:
Desire to urinate when the pouring of water
heard in case of a
is
bladder that is strongly retentive of urine, coughing of children with

whooping cough when another child coughs, coughing spell as a result
of sudden embarrassment in case of a latent irritation in the larynx.
A number of nervous symptoms are symbols (paralysis of the
organs of swallowing, because one cannot "swallow" the father's de-
mands), others are transformations, perhaps " subliminations" of sup-
pressed desires (one of Pfister's patients was an enthusiastic practi-
tioner of nature healing only when he practiced coitus interruptus) , or
identifications with persons whom one envies or loves.
A chance look may release a neurotic symptom, but only when it
connects itself with a complex. The sight of a skin eruption will only
induce the hysteric in spite of her disgust to have the eruption itself
when it reminds her (in the unconscious) of the paternal syphilis.^^^
Sometimes the affect becomes displaced from one idea to another;
the boy who years ago stole apples without having any pangs of con-
science torments himself morbidly over the matter after he has begun to
masturbate. The thought of stealing apples is more endurable than
that of onanism; the latter is therefore repressed but its affect attaches
itself to the idea of theft and gives to this a morbid severity. In such
and similar ways do compidsive ideas originate.
Another process functioning alone or more frequently in connection
with other mechanisms is the one mentioned above ^^^ of the apparent
accumulation of affects.
Not all exertions or tendencies of the wishes and fears are patho-
genic to the same degree. The most important are the sexual and those
that involve the self-importance of an individual.
A connection of the neuroses with sex, especially of the hysterical
forms, has been assumed for thousands of years, as the old name
hysteria shows. To be sure at first one thought only in the coarsest
sense of the lack of satisfaction of the animal sperma desideratis
(z= uterus), then about the middle of the preceding centur>' of condi-
tionsof irritation that had their origin in the (female) genitals
{Romberg was the leading representative of this view). But even
^See p. 136.
"^ See p. 3S.
previous to this, some {Lepois in the 17th century) had conceived
the disease as a nervous disease and later as a brain or mental disease,
and especially since Briquet, who carried it out systematically, this
view gained ground rapidly, until in the last decade of the 19th century
it became the most general. But with this all, until the most recent
times, the essence of hysteria for most people was lust and lying,
although one was visibly concerned "to deliver the poor invahds from
the odium of the sexual origin of their sufferings."
But then the sexual reappeared in the form of the Freudian doc-
trine,which placed youthful sexual experiences and repressed sexual
desires and perversities at the root of the disease. This theory has
both ardent opponents and supporters. The following is certain:
Since the instinct of hunger is usually satisfied indirectly in civilized
man, the sex instinct is by far the most important. There is good
reason for the opinion of the poet and people in general that the
love aim is the highest. But our cultural conditions demand very
unnatural limitations of the impulse, and what is much more im-

portant it is in itself ambivalent and bound up, with strong inhibi-
tions and even affects of anxiety .^^^ It thus leads to a number of
external and internal conflicts, of which, however, the latter have the
tendency to take place partly or entirely in the unconscious, the place
where the neuroses are generated. Sexual dissatisfaction, but not
merely in the earlier physical sense (in an exceptional case one may be
satisfied by a love affair or by a marriage without coitus), is an im-
portant factor in the creation of the neuroses. Now whether for the
predisposition to a (chronic) neurosis such a sexual factor is also
necessary under all circumstances cannot yet be decided. It is sig-
nificant that the severest effect of fright in the absence of a particular

predisposition rarely goes beyond the acute vasomotor-neurotic com-
plex, and that the more careful examination of neurotics reveals as a
rule (traumatics and war cases excepted) sexual conflicts, and that
the disease may often be explained by these. In the symptomatology
of schizophrenia also, sexual conflicts play an important part; in
women usually the essential part. On the other hand, a traumatic
neurosis seems to us so plainly derivable from a struggle for an income
that at present there is no reason in the case of these diseases to inject
also a sexual predisposition. It is also certain that neuroses can be
cured without directly considering sex. If a satisfying life-work is
provided, then naturally a counter-protection against injuries from sex

is also obtained.
Der Sexualwiderstand.
"^'Bleuler, Jahrbuch f. psychanlyt. und psychopath.
Forschungen. V, 1913, S. 442.
In spite of the fact that some of Freud's particular assertions will

not be maintained in the face of further experience,it is very wrong
was the fashion, and it is unscientific

to belittle this investigator, as
to allow the emotions to play such an important part in the matter.
Just as the doctrine of hypnosis and suggestion, opposed in its time
in almost the same emotional manner, and in part, with the same
arguments, nevertheless laid the first part of the foundation of a
psychopathology, so Freud has produced a great many funda-

scientific
mentals which have already given the science an entirely different
structure
and this even in his opponents to the extent that they
go into psychology at all. Without them psychopathology would
not have progressed. Much of what Freud offered was, as is usual
in such cases, not absolutely new, but he was the first to wôrk it
out into such clearness as to furnish a practical idea as the founda-
tion for further studies. To these belong the role of the unconscious,
the request on principle of comprehending psychologically all psychic
symptoms and the demonstration that this comprehension may be
often gained by the observation of all psychic connections, also in
the unconscious activities, in the dream, etc.; the clear conception of
repression, of the ubiquity and significance of inner conflicts, of the
unlimited after-effects of earlier affective experiences, of the trans-
ference of the affect to conception originally foreign to it, of the intel-
lectual conception of condensation, of the greater emphasis, even though
not yet full explanation, of the ideas of conversion (transformation
of repressed affects into physical symptoms), and of abreaction; then
the departure from the custom of ignoring the sexual life as much
as possible even in scientific matters, and the emphasis (even though
slightly exaggerated) of the significance of sex.
Besides sex, the complex to put oneself over, to distinguish one-
self, to obtain power over others is important. Many a neurosis serves
this complex primarily by compelling those who are about to act in
accordance with it.
If the self-estimation is not recognized by others, there develop from

this the many attitudes of spite that lead to changes of character ^^^
or to disease ; the young woman mentioned above ^^^ was badly treated
by her husband; after a scene she states that he should be told he had
made her sick; she developed an obviously nervous fever of short
duration and then a severe expectation neurosis, from which she her-
self suffered unspeakable pains, and which only now after forty-four
years is beginning to disappear. That was the punishment for the
'" See p. 128.
'''See p. 128.
husband. But this method of reacting is used not only toward people,
but also toward God or fate; the "purpose" is then just spite,
A peculiar way of making oneself important is finding joy in

misery: one always sees to it that one is the victim of injustice, usually
only in little things but one magnifies it into a big affair, mild perse-
cution mania, nervous symptoms, reasons for changing one's position,
etc.
Other symptoms again are compensations for feelings of inferiority.
An individual poorly endowed in certain directions wants to cover
his mistakes and appear to be extraordinary in just that respect and
for this reason seeks refuge in the neuroses.^^*
Conversely the suppression of artistic impulses, talents in general,
selection of the wrong vocations, sometimes lead to neuroses and
morbid attitudes.
all sorts of complexes, which are by chance created by the
Besides
situation (bad treatment in a subordinate position), may release
neurotic mechanisms. But it is important that clear unambiguous
endeavors, wishes and their definite suppression rarely lead to neuroses,
but almost only to ambivalent complexes.
Not entirely unimportant, unfortunately, is the iatrogenic origin
of neurotic manifestations. The physician solemnly diagnoses "en-
largement of the heart," whereupon the patient is frightened and
breaks down until the X-ray photograph resorted to by another physi-
cian relieves him of his nightmare. The stomach neurotic is not rare,
to whom a particular food had been forbidden, because of a digestive
disturbance "due to a weak stomach," who then in terror consults a
string of physicians and has some dish forbidden him by each in turn,
until he is at the point of starvation and with or without a physician's
assistance makes up his mind to eat what he pleases.
The essential part of the mechanisms that generate neuroses almost
without exception functions in the unconscious, as is indicated by the
fact that the control of our conscious personality does not extend
nearly so far as the neurotic influences (activity of the glands, produc-
tion of a twilight state, etc.).^^^ The hysterical psyche yields the
control much more to the impulses lying in the unconscious, or other-
wise expressed: these are relatively stronger in the hysterical psyche
than in the normal person.
Thus the psychology of the affectivity and the unconscious give
the key to the understanding of the neuroses and of many psychotic
^^
Comp. especially the works of Alfred Adler.
'''^Therefore Babinf<ki's limitation of hysteria to his pithiatism, i.e. to con-
ceptions which are accessible to the (conscious) will, cannot be accepted.

symptoms; the corresponding mechanisms are present in every person,

"everybody is capable of hysteria." The healthy person also has
wishes in his unconscious, which conflict with his conscious personal-
ity, some of which now and then manifest themselves in "the psycho-
pathology of every day life," i.e. in errors, forgetting, and in dream.s.
But the healthier a person is, must be, in

the stronger the affect
order that its results can be exaggerated into neurotic symptoms.
In this respect acute injuries relatively seldom produce an effect and
primarily only an acute effect, chronic injuries more easily produce
lasting symptoms; but the most readily effective disease producers
are acute, serious experiences after a chronic impairment of resistance
and the gradual accumulation of restrained affects. But when a
protracted or general neurosis is developed from a transient symptom,
then there usually exists not only some conscious or unconscious wish
to be sick or to transjorm reality by means of the phantasy, but a
psychopathic predisposition also. Even pronounced fright neuroses
during earthquakes and similar catastrophes were seen onl}^ in psycho-
pathic people, and there too they passed away. The wish alone, be
it ever so strong, cannot at all produce a neurosis. During the last
war thousands had the wish to be freed from the hell by some disease,
but the disease did not appear in most cases certainly not because
of moral and other opposing considerations. One, i.e. the unconscious,
7nust know the path to definite symptoms in order to travel along it.
By means of trembling during fright from a shrapnel explosion many
were shown the path from now on the unconscious remembrance of it
;
could again release the trembling reflex, as often and as long as was
necessary. All the chronic impacts also could finally even though
not frequently hystericise the person wuth healthy nerves, i.e. make
it possible for him to produce hysterical symptoms, perhaps along the
path of mere physical nervous weakening, but in any case by means

of the fact that the future patients experience in themselves the sensa-
tion of a number of morbid or "nervous" symptoms, for the release
of which they have now found the path of association. The concept
of hystericising thus contains the dispositional factor, which mani-
fests itself in some weakening of the resistive capacity, and in road
building between the idea and the symptoms.
The above material distinguishes only certain types. In reality
the most different dispositions, mechanisms aiid syndromes inter-
mingle and influence each other. Therefore it is impossible on principle
to produce a division of the iieuroscs into properly defined entities, be
it according to disposition, releasing causes, mechanisms, or syndromes.
In this case one must clarify the various possibilities, and then see in
the particular case which of them is realized. Relatively pure cases
are e.g. the monosymptomatic hysterias of children, many of the
trembling neuroses, many compulsion For the remaining
neuroses.
the disposition and mechanisms should be described, which is not pos-
sible to a sufficient extent; besides, one should also know the more
frequent groupings of dispositions and symptoms and their connections,
which unfortunately has not been adequately attained. Nevertheless
we understand fairly well why hysterical symptoms frequently occur
in "nervous" characters: without excessive domination, facile irrita-
bility, and no hysteria can develop.
lability of the affects,
Also the combination of hysteriform symptoms with
frequent
pseudologia is at once comprehensible. Both syndromes want to sham
something for themselves and others; they require an affectivity of
strong effective force but labile, an easily influenced spirit and an
exaggerated self-esteem. The (pseudo-) neurasthenic symptom com-
plex,which represents a failure, is usually connected with a depressive
fundamental mood, etc.
Just as among themselves, the psychopathic reaction forms cannot
be sharply defined from other morbid groups also, and especially not
from the psychopathies on the basis of which they develop, so that
it is often arbitrary whether in a morbid picture one wants to emphasize
the psychopathic disposition or the released reaction symptoms. There
probably are constitutional, one-sided homosexuals; but in bisexuality
chance connections and attitudes determine whether the homo- or the
heterosexual components shall finally dominate. Many place the
hysterical character in the foreground, others the symptoms; the
anomaly of "the impulsive people" lies in some in the native charac-
teristics, in others it is a reaction system. Kraepelin includes the com-
pulsive forms in the original morbid states ;we include them with most
of the others in the reactions, etc. At all events one should talk of
hysteria and neurasthenia only, when on the top of the "nervous^' or
"psychopathic" foundation there is a distinctly acquired morbid atti-
tude, or when one wishes to impress the patient with the possibility
or expectation of an improvement.
Among the psychopathic reactions we distinguish: the symptomatic
intellectualforms of paranoia, of the delusions of persecution of those
hard of hearing and of induced insanity, the reactive changes of
character, the reactive impulses (states of wandering, kleptomania,
pyromania, the neuroses, and among these hysteria (pseudo) neuras-
thenia, the expectation neuroses, and the compulsion neuroses, but we
want to call attention again to the fact that it is merely a question
of an artificial separation of syndrome groups, which, genetically and
symptomaticalily usually intermingle and pass over into one another.

,
But same syndromes also occur on the basis of process psychoses,

the
especially in schizophrenia and in a more limited manner in epilepsy;
only when they apparently occur "independently" can they be consid-
ered as neuroses. For practical reasons two groups are circumscribed
etiologically: the prison psychoses and the traumatic neuroses.
In the compulsive forms the prospects are not very good.'"'" In
the following we speak only and neurasthenia: Their
of hysteria
curability depends primarily on the severity and extent of the psycho-
pathic predisposition. If the disease is only a partial symptom of a
twisted character which cannot get along either with people or with
fortune, naturally little can be expected; for even if the symptoms
were cured it would still leave a very sick person. More serious moral
defects alone also hinder the cure. Especially in children a distinc-
tion should be made as much as possible between the generally abnor-
mal with hysterical syndromes and those with a good constitution, who
suffer from nervous symptoms only under the pressure of circumstances.
The former are almost incurable; the latter with proper treatment
usually regain their health quickly and in later life rarely become
sick again.
Concerning the curability of the two neuroses in themselves, or to
speak concretely, of those cases not associated with other abnormities,
there is a difference of opinion according to whether one does not in-
clude the nervous disposition in the conception. At all events the
symptoms are all curable even though all are not really cured. The
neurosis does not lead to dementia. The worst obstacle to a cure
exists when the patient, consciously or unconsciously, does not want
to be cured. One simply can neither directly stimulate the inadequate
energy so that the patient takes up the struggle of existence even under
unfavorable conditions, nor can one often improve the situation so that
no reason for being sick exists. But most patients are improved by
treatment or are freed from their symptoms. Naturally the dispo-
sition is not cured, if, as is usual, it is congenital. Hence relapses are
very common, whereby still other reasons cooperate (life cannot be
constituted according to our desires, especially when the desire consists
in wanting to shine without continuous achievement). It must not
be forgotten that if the energy, wrongly applied for purposes of the
disease, is led into channels that are proper and commensurate with
the patient's endeavors, such people w'ith their undivided application
of their ability can accomplish more than the healthy. What hinders
their activity is simply split off, and the far-reaching domination of
^See special discussion.
the vegetative functions by the psyche instead of being used for the
production of physical morbid symptoms is used in the service of the
new task. While formerly they could not sleep, they now do not
need to sleep much; the system of metabolism that permitted the
hysteric to retain his weight with a very small amount of nourishment
may with a slightly different application become a very useful
inexhaustibility of strength.
The general diagnosis of the psychogenic reactions is based, in the
on the recognition of the psychogenic mechanism which is
first place,
usually not difficult. The most important and also the most difficult
part of the diagnosis, consists in the exclusion of a somatic (or
psychotic) foundation by means of a careful investigation. The same
mechanisms dominate schizophrenia, are frequent in epilepsy and all
organic brain diseases, and may be released by any sort of physical
diseases. Therefore one must know as exactly as possible what can be
reactive and what cannot. It is impossible to enumerate the details
in this place ; but this is hardly to be regretted because one could not
get finished with it anyway, and only he who besides some experience
in the appearance of the morbid pictures possesses the general concep-
tions of the nature of the reactive symptoms can manage to get along.
But even the most experienced will occasionally have to leave a diag-
nosis open for some time.
If one finds signs of schizophrenia or of
paresis, then to be sure the matter is settled, but if a physical disease
also exists, it may be difficult to recognize the kind and the significance
of the psychogenic elements. One should keep in mind that the
neuroses leave the ideas intact and do not produce obstructions without
a comprehensible affective foundation. Hysterical indifference is
very rare, and may be usually differentiated from the schizophrenic
by means of its perspicuous genesis and its yielding to influence.
Rigidity of a pronounced affect will probably hardly ever be hysterical.
With the neurotic and especially with the hysteric one usually has a
pronounced affective rapport, be it positive or negative. Whoever does
not show the physician any deeper feelings in the course of a protracted
examination is no mere nervous case.
The general treatment will be mentioned here only to the extent
that it concerns the neuroses. The disposition can be influenced in
very few cases. Where conditions of weakness of any sort are present,
one will naturally combat them. It is more readily conceivable to
remove the conditions out of which the syndromes grew or were nour-
ished. Above all, wherever possible, a life work should be provided
for the patient in which not only the external conditions are to be
considered but also the internal which induced the patient to decline
a life work. The will or the desire to be sick should, if posnible, be

overcompensated by positive endeavors which presume health.
For the rest, one can attack the symptoms by direct suggestion
with or without hypnosis; or one can conceal the suggestion in any
other remedy or procedures, if possible in such as under the given
conditions really have a curative effect in any incidental matter
(climate, mountain climate, water,'" etc.). If the patient feels better
externally, he gets along. Spontaneously or with skilfull instigation
he makes plans for the future; briefly, he changes his attitude so that
a subsequent reduction of physical energy cannot do so much harm.
For (apparently) localized symptoms local treatment should not if
possible be undertaken, because it would frequently strengthen the
patient's idea that the disease is localized there; still less will one
lower oneself to resort to fictitious operations. Miraculous remedies,
from any sort of mystery pills up to a pilgrimage, may naturally also
help. In the form of Dubois' "Persuasion" one can combine the sug-
gestion of which both physician and patient are unconscious with a
sort of training and enlightenment. This depends on the taste of the
patient and still more on that of the physician. Psychoanalysis which
brings the morbid mechanisms into consciousness or causes an "abreca-
tion" of them cures many cases. Where it can be done, one will
"subliminate" the pathogenic impulses, divert them into similar but
useful channels and supplant associations having a morbid effect by
more favorable ones. Isolation is often important or at least separa-
tion from an environment which is impressed by the patient's suffering
or shows sympathy with him especially in the case of severe hysterias
;
of children, this measure is usually a necessary condition of the cure.

On the other hand, the deliberate ignoring, the refusal to be impressed
by apparently the severest symptoms, is an excellent remedy. A hys-
terical attack and many another symptom is really an exhibition.
If one takes care that the spectators disappear at once when the
exhibition begins (preferably by isolating the patient) then the entire ,
arrangement is usually deprived of justification for existence, and it

is given up in the shortest time. In general if by changing the inner
or outer circumstances one can make the neurosis futile, naturally much
"^^
Drugs as direct remedies against neuroses are to be avoided as much as
possible. They divert both physician and patient from the true conception of
the disease. If they have no effect, they have for that reason ah-eady done
harm. If by chance they are effective, the cure is bound down to them and they
have to be continued mildly until a change of conception renders them in-
effective. It goes without saying that morphine should not be given. For
incidental purposes one will naturally not want to dispense entirely with chemical
remedies: Bromide for sleeplessness, iron for accompanying anemia, etc.
is gained. ^Where physical resistance has been reduced, one will try
to increase it, be it to deprive the disease of its foundation, or effec-
tively to support the suggestion of health.
If matters improve, then a thorough training must follow in which
a sensible manner of living must not be forgotten and thereupon a
proper initiation into life. What one does in the neurosis is a detail;
the only decisive thing, is how one does it, and how one stands to the
patient. Some think that for this reason they have to become friendly
with the patient, others consider this dangerous; if only there is a
personal relation to the physician, one can overwhelm or impress or
persuade the patient or use suggestion on him; here too the remedy
is a detail. It goes without saying that for psychotherapy generally
and for the application of every individual remedy special innate
qualities are necessary, in which respect unfortunately many a quack
is superior to the trained physician; added to this there must be pro-
fessional experience, exact observation of the individual patient and
his manner of reacting, and the weighing of the many accompanying
conditions that have to be considered.
Prevention. The congenital neurotic disposition cannot be readily
combatted except by the avoidance of the marriage of "neuropathic"
people. A disposition acquired by disease or by unfavorable life
experiences usually disappears without our intervention. One cannot
evade the inner and outer conflicts at will; on the other hand, they
can be subdued by creating a purpose in life; to be sure the normal
person does not have to do this consciously, and on the other hand
many a severe and characterless psychopath will be unable to form
one or hold to it. But in the cases that lie between these extremes it
depends on the attitude and the circumstances, matters that to some
extent can be controlled. One can create a purpose in life or have
one pointed out by another person. Every task is interesting as soon
as one has gained sufficient associations in connection with it. Here
one should not forget that most hysterics, like women, are more easily
interested in things having a directly affective element, especially in
personal things. On the other hand, a rigorous disciplining of think-
ing by dealing with tangible realities can counteract the emotionalism.
But the 'health conscience" above all is amenable to educative influ-
ences. Whoever from youth onward is accustomed to treat his feelings
of ill health as an inferiority and disagreeableness, whoever in child-
hood experience no advantage but always only obstructions from dis-
produce a neurosis. One has to create a "pride
ease, will not so easily
in health" (Gesundheitstrotz) even during the training of childhood,
and where this has been neglected the physician should make it up
as far as possible ; but this feeling must not be mistaken for the health
nonsense of psychopaths, who want to keep well by means of some
system and are therefore incessantly on the watch for symptoms of
health and disease.
For the prophylaxis in the case of psychopathic children Ziehen
gives the following noteworthy rules:
L Total abstinence from coffee, tea, alcohol, spices and tobacco
up to and including puberty.
2. Supervision of the sexual life.
3.Hardening by cool rub-downs and cool baths; habituation to

pain and exertion; regular gymnastics (eventually also sports). Care-
ful restraint of the development of the phantasy (supervision of read-
ing, care in leaving them alone, etc.) ; favoring all objective occupations
(collections of all kinds, construction, drawing; later also painting

from models or from nature, open air games with other children, etc.).
The daily routine in all cases should be regulated by a definite schedule.
4. Attendance of a public school is, as a rule, preferable to private
instruction.
5. In case of unfavorable home conditions (unfavorable example of
the parents, coddling by the parents, etc.), education outside of the
parental home in a private school or in a suitable boarding place or
in the country with a teacher, physician, or minister should be pre-
scribed; in more severe cases the so-called pedagogical sanatoria
(schools with medical supervision), like those first founded by
Kahlbaum, should be considered.
Habituation to obedience and self-control by means of a calm
6.
severity. Passionate scolding is almost never successful. Corporal

punishments also are rarely effective nevertheless they are permissible
;
to the same degree as in the case of normal children. Other punish-

ments (deprivation of pleasure, etc.), are not only allowed but when
sensibly applied are, as a rule, effective.
1. Paranoia
As the clinic can only rarely exhibit paranoiacs, it is in place here
to present somewhat more detailed examples for purposes of
orientation:
Delusions of Persecution. Engineer, born 1855. Father was an
unsteady farmer, who did not like to work, during manhood felt him-
self persecuted in a vague way and hanged himself during an attack
of delirium tremens. The father's father was a drunkard. Three
brothers of the patient are unmarried, unsteady like the father; two are
relatively steady, one is a drunkard. One sister is married, normal,
has children. Patient was a capable, cheerful boy, but somewhat shy
toward Mechanic's apprentice, then in a technical school,
strangers.
then a skilled mechanic. Hoped to become distinguished. The future
partner of the machine factory S. was his schoolmate. At the final
examination of the technical school the patient exhibited a drawing,
which he expected would make a name for him, but he was keenly
disappointed when it was praised and then forgotten. He was a good
marksman but even for his prizes he received too little recognition.
He thought of journeying to the Cape of Good Hope with his brother,
got as far as Marseilles, heard there that no steamer would leave. The
brother travelled by way of Genoa, but the patient returned home,
took a position in a branch of the firm S. in England but felt uncom-
fortable after a second, larger firm, R., in his native town him
offered
a position that he refused. He believed that now the firm R. would
be put out about it. When the offer was made to him that his present
position be made secure for three years, he suspected that the firm
wanted to take advantage of him, and left his position. Then there
began a wandering existence for twenty years contrary to his will:
when he had a good position, he heard remarks that he was ungrateful
toward the firm S., that he was an engineer who did not know algebra,
and similar things. In reality they were random remarks that he
wrongly applied to himself and memory deceptions in which to accord
with his delusion he changed something in words he had heard. Some
one said, "You will soon see"; he referred this to himself as a threat.
He was in all sorts of places in Europe and America, and several
times returned temporarily to an old position, but he was always
driven away by such remarks. He devised reasons why the firms
R and S., with the assistance of the association of former engineering
students and in other ways, pursued him to take revenge on him, and
at the same time to make use of his talent. "They simply gave the
assignment to an agency and had me persecuted."
People were supposed to have ascertained where he was going and
sometimes even to have sent the news in advance. Once he defended
himself in an insulting letter to the firm, which naturally understood
nothing about it. Often he felt safe for a time in some new place,
but if he had to write home, it began again because the postal authori-
ties opened his letters and gave his address to his persecutors. In
restaurants people put their heads together when he entered. Special
arrangments were made to make him acquainted with women, who
should tempt him to all sorts of excesses so that he could then be
exposed as a high flyer. Often care was taken that he did not get a
position until he had used up all his savings this was done so that he
;
would become dependent on his new employers. Because his money

had to go anyway, he began to drink Rhine wine and smoke Havana
cigars and habituated himself gcneraliy to drink more than was good
for him. In America he got married but did not take his wife with
him when he was again "driven away," and more or less forgot her.
Several times he wanted to start his own business but never got beyond
the purpose. With the laborers he conversed little; he was too proud
to do it. Once, when he returned to ZUrich he felt that he was being
observed by a sanitary policeman. That was possible because he had
sent his photograph to Zurich. He wrote an essay on a Utopia which
was no better than similar efforts but of which he was very proud.
A few months before his admission to Burgholzli in 1897 he was a
construction draughtsman. His fellow employees began to smirk,
sometimes to laugh, all on his account. His superiors annoyed him.
Once a drawing was lost; he was pointed to as the guilty person.
People peeped through the key hole when he washed his privates in
the water closet, and told others about it. People "made a big fuss
about a few youthful errors" and said everj'where that he masturbated.
In this way he lost his honor and the possibility of making a living,
because no one wanted to employ a person of that sort. He would be
a scoundrel if he had tolerated this and so he shot his superior from
ambush. In the hospital for the insane his conduct was normal exter-
nally. At first he was visibly frightened at the result of his shooting.
After he had openly stated the above motive ôr several days and
claimed to have acted in self-defense, he framed excuses which he evi-
dently believed himself (gun went off accidentally, then again that he
had been confused, etc.). On the whole he was distrustful, friendly,
worked in the printing shop of the hospital and besides tried to make
all sorts of inventions (a milling machine which was usable but already
equalled by one just as good, a steam engine without a swinging piston

in which, to be sure, something was still lacking) . At first he tried to
carry on his studies "as secretly as possible"; after a while he became
accustomed to the society of the others.
He spun out his delusions in various directions. In the remissions
he could also correct some things; thus he once thought "Messrs. R.
and S. only wanted to watch him but not persecute him"; "they simply
suffered from fixed ideas." But soon after he took up the old system
again. New delusions also turned up: in his ward there was a homo-
sexual. Now people nudged and winked that he too was perverse.
Furuncles that he had on his neck had been injected into him by the
orderly. In his ward there were by chance several former employees
of his last firm.' They probably had to observe him, etc.; the delusion
also developed retroactively in the form of memory deceptions. S. had
already persecuted him in school. Chapters of a certain law had been
used against him (this at a time when this law did not exist at all).
He thought the murdered superior had dismissed him in disgrace,
while in reality the patient had resigned. At certain times the delu-
sional system merged into the background; at other times he occupied
himself entirely with it, at the same time developing it further.
Noticeably early the patient showed signs of psychical senility.
With this there now came more pronounced ideas of greatness that
could not very well be sustained logically any longer: A second court
of justice would liberate him. One judge or another had promised
him to take up his cause. An uncle had left him a house and later an
enormous fortune. Finally he suspected that he was not his father's
son. All of this was supported in the form of memory deceptions.
Even previously, 1907, he had escaped, but in spit of the fact that
he had been helped with money, he only got as far as France and there
thought it best to return to the asylum of his own accord. Without
feeling that in this way he had hurt his position, he thought he had
now proven that he could be discharged, and he planned to become a
store-keeper.
Pathology: An excellent man with a certain amount of inventive
ability cannot execute his ambitious plans because he has too little
enduring energy. He thinks that a good drawing that he exhibited
and a few medals that he won at rifle shooting should immediately
open the way to distinction. Conversely, when in Marseilles there
was no boat to the Cape of Good Hope and, likewise, when after his
escape from the asylum he had trouble in making his way, he lost
his courage. In sexual matters he was just as weak; he was married
but simply abandoned his wife, not with deliberation but just because
it happened so. He refused an offered position, found out later that
he should not have done this and then thought that the people who
offered him the position began to annoy him. They had assigned his
persecution to an agency. The delusion has developed into a system
and was supported by incessant ideas of reference and newly created

memory deceptions. Now this plain case of paranoia also has two
complications that belong to other diseases; in the nineties the patient
had, during the course of his paranoia, a brain disease, probably a
gumma, and at that time was not quite clear in his thoughts for a
brief period. From then on his memory, on very careful inspection,
was no longer as good as formerly. It may be assumed that for this
reason the memory deceptions appeared so easily, which already after
a few days attached themselves to his act of murder, at first motivated
by himself in an entirely clear manner. The same may be said of

his premature mental senility. Moreover he had committed alcoholic
excesses in the weeks preceding the murder, and had undergone a mild
alcoholically tinged delirium. At that time, but only then, did he
hallucinate. It must be assumed that this unenergetic man would
never have gone as far as to shoot his persecutor without this alcoholic
excitation.
Erotic Delusions of Grandeur with Delusions of Persecution:
Daughter of aristocratic but not well to do parents, born in 1848,
brought up at home with a classical education, is said to have covered
in three months the work of each year in college. Associated with
scholars. She wanted to investigate a definite, important historical
subject but permitted herself to be diverted and wrote something
different. Then she undertook a new historical problem which she
gave up to care for her sick parents. At the same time she had pleas-
ant social intercourse with acquaintances and friends. At thirty-six
she went to a brother, whose wife had died, to keep house for him, but
paid him her board to be on an equal footing with him. Two years
later she was again at home. In the meantime her feminine instincts
were aroused: "I felt that at bottom I was disposed to be very
domestic; although I again plunged into society, nevertheless I did not
know what to do with myself." She wanted to become a nurse but in
some way did not get along with the authorities. In a sort of despera-
tion she let herself be driven into marriage with a less aristocratic but
evidently very refined man. As late as eightdays before the wedding
the future couple discussed a separation. However, the marriage was
consummated but was soon followed by a legal separation. Later when
I remarked to the patient that her husband had acted very generously
in the matter, she thought: "According to what I saw, he did. Accord-
ing to what I heard later but cannot prove, he did not." As the
patient was a Catholic and thought of marrying again, the separation
gave her qualms of conscience. Probably a little later she formed
the delusion that the archbishop had annulled her marriage. But
before she was separated she believed that men of high rank wanted
to marry her. They themselves, as well as other people, had proven
this by their "hints." But nothing happened because intrigues against
it had been undertaken and she was being slandered. She defended
herself against this. Insanity was suspected. A psychiatrist evidently
on the occasion of the separation, had given an opinion to that effect.
She wrote to him that he was a scoundrel and she then believed that
he had thereupon given a second opinion, declaring her sane. She
was then put under guardianship and was afraid of being committed.
Even during the trial she fled to foreign countries and wanted to have
herself certified to by a psychiatrist; but when she ascertained that
he was known in a city where one of her supposed admirers lived, she
was convinced that with the help of the courts he wanted to sur-
render her. She then went to a Swiss University where, as she thought,
she was slandered as crazy and syphilitic and in other respects. As
she feared being interned, although there was no reason for it, she
once fled to another university and obtained her Ph.D. magna cum
laude. Thereupon she looked for positions but found none, travelled
around everywhere, in other parts of the world also, always felt her-
self pursued, especially when she sent off a letter; she wrote a pamphlet
on German justice embodying her delusions. Meanwhile she again
imagined proposals of marriage from prominent people, intercepted
telegrams, opinions, and acts of people of the highest rank, of which
nothing in reality existed. Everything influenced her being either in
a friendly or hostile manner. After a while the patient calmed down
somewhat but always believed herself pursued by everybody that had
had anything to do with her. She produced articles and, which was
significant, liked to write about secret societies. Characteristic of the
case is the fact of the predominance of scientific interests over the
erotic until she had kept house and had reached the critical age.
Only then did she have a desire for a home of her own but at the
same time also for an elevation in rank; an unfortunate marriage not
based on any erotic feelings; delusions of being desired in marriage
by people of distinction, imaginary failure of a marriage because of
intrigues and slanders. In spite of the patient's very high intelhgence
and her education, she was absolutely incapable of correcting the most
senseless delusions even when confronted with them, as, for instance,
that a psychiatrist in a university to which he did not belong demanded

her dismissal, that in America she could be brought into an insane
asylum by a nurse without any further formalities, etc. But with
was capable of obtaining her Ph.D. magna cum
this all she laude.
The way she herself described the origin of her combinations from
hints is very pretty: "I heard the whole thing bit by bit; now one
gave me a hint, then another, and I put this story together like a
mosaic."
Persecutory Delusion and Litigiousness. Author, born 1857 college ;
education; since his twenty-fifth year hard of hearing and then deaf.
He worked on a newspaper, had a good income, was generous toward
his brothers and sisters but saved nothing for himself. In early youth
there were also a few signs of frivolity. Because of the expense of
his education, he had given up his claim to his share of his father's
THE INJJIVIDUAL MENTAL DISEASES 515
estate, as a second brother had done. Toward the end of the nineties
he became more sensitive. He no lonjêr got along with the sinter
with whom he lived and with his colleagues on the newspaper; resigned
and tried to obtain a position in a foreign place but failed. He then
made adventurous, if not exactly gigantic, business plans that were
quite foreign to his previous calling and became poor. Then there
began a struggle for existence, i.e., for a legacy that was supposedly
so large that he could live on it if he had to. He tried to retract his
waiver of his father's estate. When the father made a will he never-
theless left him one third of the estate that he would have had with-
out question; he went home, raised a riot, and wanted to compel the
writing of another will. He attacked the existing will with all sorts
of pretenses, maintained that the father had promised him not only
his own share but also that of a deceased sister; he stole papers from
his father. After the father's death, which followed soon, a brother-
in-law made an arrangement with him that he wôuld pay him more
than his share if he would be satisfied and give up the papers. But
the patient did not give up the papers and soon demanded more (be-
cause he could not live on what had been promised him). In court
he accused his sister and brother-in-law of fraud, duress, concealing
the estate, perjury and other crimes. As the courts did not decide
in his favor, they too were attacked, partly in countless petitions and
appeals, partly in the newspapers; the latter in such a manner that
he convinced people of note of the injustice of the judiciary. He also
got into litigation with his own lawyer, refusing to pay him his fee.
To be sure, here and there he lied; but on the whole he believed
in the justice of his cause. He did not notice that he never proved
anything. He readily moved in a circle: The brother-in-law got his
share; proof: otherwise he would not have raised a riot; the brother-
in-law raised a riot; proof: otherwise he W'Ould not have obtained

anything (naturally the nonsense of these conclusions is concealed
in a mass of words). Facts necessary for the purpose were simply
invented (memory illusions) The letters that did not suit the patient
.
he declared to be forgeries; he knew at once who dictated them.

In this case the disturbance of thought extends to mathematics.
The patient is not capable of figuring a problem of practical im-
portance to himself: If six brothers and sisters have to divide a
fortune of 50,000 Fr. in such a way that three obtain only the legal
minimum, how much does each obtain? He mixed up everything
about the legal minimum and and always mistook the ideas
total,
in such a way that something big for himself always turned up. A
discussion lasting several days could not enlighten him. Other con-
ceptions also, that were simple for him, became unclear where it coin-
cided with his purpose. Thus he would not keep apart the laws of
inheritance and the laws of sales. He could not identify the same
events when they concerned himself or an opponent. His unconscious
but solely decisive "logic" was an affective one: He was in want; his
brothers and sisters were better situated; he needed the inheritance
much more than'they. The understanding was present only to support
the realization of this wish. He formed ideas without any reason
whatever (chiefly memory deceptions but also suppositions concerning
relations) ; what contradicted his ideas was simply not brought into
logical connection. He was entirely incapable of discussion. It was
a certainty for him that the court and his brothers and sisters defrauded
him; for him everything followed from that. He could not, conversely,
prove the crime from the facts. For him the crime was the axiom
from which he started. He could not see the viewpoint of others
who demanded proof. For him everything was "logically demonstrable,
proven, self-evident, not requiring proof; he has experienced it on his
own body."
After the appointing of a guardian and the rejection of his suit
the patient still remained active for some time; convinced, among
others, a well-known, distinguished author of "the fact that he had
found no protection in psychiatry," but seemed to have calmed down
somewhat after a while. At all events, unlike the pure litigant, he
has given up his court actions. It is significant that he prefers to write
about super-men a la Napoleon.
The Wagner case; Delusions of Grandeur and Persecution;
Multiple murder and Incendiarism}^^ During the night from the third
to the fourth of September, 1913, the Headmaster Wagner, thirty-nine
years old, murdered his four children and his wife while they were
sleeping; the following night he set fire to several houses in another
village where he had previously been a teacher, and was shooting at
the male inhabitants, of whom he killed nine and seriously wounded
eleven. Even as a boy he was easily insulted, ambitious, conceited.
Later he had poetic plans for reforming the universe. His sexuality in
respect to the animal impulse was strong, but he had a "disinclination"
toward marriage and evidently no parental instinct, even though he
loved his children in an ordinary human way.
His highly developed self-esteem had been deeply depressed by a
futile struggle of many years against onanism. Later (1901), under
the influence of alcohol, he had let himself be carried away to sodomy,
^ After Gaupp, Zur Psychologie des Massenmords, I. Bd. 3. Heft der Ver-
brechertypen. Edited by W. Gruhle and A. Wetzel. Springer, Beriin, 1914.
and then had a dreadful feeling of sin with incessant fear of contempt
and arrest, which soon brought about delusions of reference and the
conviction that the inhabitants of the village knew of his crime and
spoke about it.
His accusations against himself he transferred to his family; all

"Wagners" should be exterminated; then his hatred extended to all
mankind, above all to the inhabitants of his district who had treated
him badly. He condemned himself doubly, in part as a man unworthy
of this life, but in part as a genius whom he honored as at least equal
to the greatest poets, but whom he also ranked as equal and superior
to Nero, and, on the other hand, compared with Christ. Transferred
in 1902 to another place, he enjoyed relative quiet for six or seven
years without, however, ever ceasing to build up further his delusional
system. But then, according to his opinion, the remarks and contempt
continued there also. The result was the plan, even then developed in
every detail, to murder his family as much because of reasons of race-
hygiene as from pity, and then set fire to the village where he was
first employed, and destroy it with all its hypocritical inhabitants.
The first necessity was the extermination, the "redemption" of his

children; but the revenge against, and contempt for, the village occu-
pied him no less. His wife he had to kill because of pity. For a
person like him there are special laws. He had not only the right
but the duty to do this. His plan was a "humanitarian matter." For
four years he postponed the execution of the bitter task. But when he
was later transferred to a third locality and there felt himself the
centre of bar-room gossip, he executed his plan systematically. In
his feelings, as in his self-estimation, he was completely ambivalent:
he could not witness the killing of a chicken, did not like to see blood
generally. In the insane asylum also he was so soft during the visits
he denied them to himself, and with all this, he had
of relatives that
made and also executed the bloodiest plans.^^^
The modern morbid picture of paranoia was created by Kraepelin;
according to him it is characterized by "the furtive development, re-
sulting from inner causes, of a lasting, immovable delusional system
that accom^panied by the complete retention of clearness and order
is
in thinking, willing, and acting." Formerly many kinds of diseases

were designated by this name. Toward the end of the last century
itwas believed that the essence of the disease was to be found in the
more or less isolated disturbance of the understanding; as every de-
lusional idea and every hallucination represents such a disturbance,
most mental diseases could be included in this, and this was preferably
** Comp. p. 531, his remarks on the brutality of weakness.
done. On the basis of this stereotyped conception acute forms with
delusions and hallucinations were also included. As such acute syn-
dromes usually belong to schizophrenia which later readily exhibits
chronic delusions, the theoretical confusion of acute and chronic con-
ditions, different in principle, could not appear as senseless at the
patient's bedside as it really was. But the morbid pictures of Kraepe-
lin's paranoia and the acute forms of insanity that were included
belong together about as much as typhus and a fracture of the leg,
both of which hinder walking and keep the patient in bed.
There was a better development of the paranoia concept among
the French, who in penetrating studies clarified the psychology of
the forms of delusions but could not exclude dementia precox, and
sought classifications according to the content of the delusion.
The essence of paranoia is the delusional system, i.e. a structure
of delusions that all have a certain logical connection and contain no
inner contradictions, even though the logic is not in all cases com-
pelling. That the delusion nevertheless strikes the normal person
as not only insufficiently supported, but also as senseless, is due
chiefly to the false premises and the shutting off of criticism. Year
in and year out, no matter in what corner of the world they are, the
patients are pursued by a conspiracy of people, or they would have
made great inventions, the practical elaboration and utilization of
which is being hindered, or they are high servants of the crown, proph-
ets, etc., who want to establish their claims.
Only the persecuted patients are as yet known more exactly; our
description, therefore, is only to be carried over to the other forms
with care.
The false premises are morbid references to the self, and memory
deceptions. In a certain direction the patients have an exaggerated
readiness of association; they bring a number of entirely indifferent
or unimpeachable occurrences into relation with themselves. Children
run after the wagon in which the paranoiac is riding; they mock him
or show the high position that he will hold. Some one coughs; that
is a sign that he must be on his guard or that he does not belong here
or that another should be on his guard for him. Some one yawns ; that
means that he is two people are together and laugh, then they
lazy; if
are laughing about him. In the newspaper there is an expression that

he has used recently; therefore the entire article is stolen from him.
A higher official has looked up at his window; he has an important
mission for him or he knows that he is the future sovereign. The
minister preaches about Judas: the whole congregation knew that he
(the patient) was the person meant. On the street everybody looked
at him significantly. Between the event and the interpretation in

the sense of the self-refercnoe delusion there usually intervenes a latent
period of from hours to years, most frequently of about a day. While
the healthy person usually works over his experiences subsequently
(consciously or more commonly unconsciously) in the sense of a many
sided connection with reality and a correction of possibly wrong con-
ceptions, th^ paranoiac connects his perceptions during the latent period
with the delusions and falsifies them in the same direction.
Sometimes the patient's assertions seem so senseless that one has
to ask towhat extent sensory illusions are involved. Beside the most
commonplace occurrences the patients are also accustomed to tell
some that are altogether impossible. To illustrate: In spite of the
fact that they came into the theatre without a sound, the entire audi-
ence looked around at them; the minister spoke of things that he
could not possibly know from ordinary sources; a respectable person
stuck his tongue out at them. Of course here and there real illusions
may play a part as in every healthy affect. But whenever I could
investigate carefully I found that sensations and perceptions were
absolutely correct, but the patient transformed them, of course often
immediately after the perception, and later in his tninking he operated
only with these transformed pseudo-perceptions which he took to be
real. Hence there are already involved here added memory deceptions
which, to be sure, occur also in normal people. There are people who
only subsequently falsify their recollections in the sense of offenses.
The complicated memory illusions which represent complete trans-
act seem clearer to us.^^ At this and that consultation which
really took place, the physiciansupposed to have said that the patient
is
was sound, that the expected elevation in rank would occur in one
year. The waiter brought the patient a glass of brandy; later he is
convinced that the brother-in-law who is accused of poisoning served
him. His wife met a certain man on the stairs; later he believes she
made signs to him were understood and replied to.
in passing that
Between the event and the complete transformation there usually
intervenes a considerable lapse of time, at least a night, often much
more, a year, even a decade. Supported by continually repeated "ex-
periences" of this sort, the patient must come, in an entirely logical
way,^*^ to the conception that people have something particularly
in mind about him, he goes further and knows also ichat they have
""See pp. 105-106.
^" In the paranoid form of dereistic thinking the logic must also be included,
but it is here essentially supported by the fact that the elementary- impulses
run in the same direction; the wish to be something special is already at the
root of the disease.
in mind. They want to persecute him or prepare for his future eleva-
tion, and he knows why they proceed in this manner. The latter he
has naturally not been able to conclude in a compelling manner; but
"as the chief factor is a certainty for him, inferences based on probability
which he considers certain suffice for him. A general criticism is im-
possible. To be sure, occasionally he may admit that one or another
of his partial ideas is not sufficiently proven or even that it is false.
But for that reason everything else is nevertheless a certainty beyond

a peradventure.
Outside of the delusional system and everything that refers to it,
his logic and train of ideas are sound according to our means of investi-
gation. If he is otherwise intelligent, he can be a minister, architect,
or high school teacher and, aside from indirect difficulties resulting
from the delusions, can do very well in his calling. In everything con-
nected with the delusions, paranoiacs are very gullible about corrob-
orating statements and, on the other hand, readily distrust everything
that does not suit them. It seems that this feature also frequently
shows itself outside of the delusion, be it because, beginning with the
disease, it has become generalized, or because it belongs to the patient's

individual character.
In the other functions also one can recognize no primary
disturbances.
Sensations and perceptions are sound. Hallucinations are nearly
always lacking; but one must not say that they are entirely excluded
because that is not the case even in normal people; but in paranoiacs
there are occasionally strong excitements or also ecstasies that may
run their course with hallucinations. When this is the case hearing
and sight are probably affected most; in severe acute conditions per-
haps also smell and taste.
Memory, aside from the illusions, is good. Memory hallucinations
will probably not occur. Naturally the one-sided interest of the
patients also produces a one-sided preference for individual cate-
gories of memory material.
Orientation as to place and time always remains normal, except
perhaps in the very rare psychogenic twilight states.
Attention corresponds to the preoccupation with the delusions; if
these are once taken for granted it is normal. At any rate, one can
call the readiness of association for everything that can be utilized
by the delusion a one-sided tendency of the attention. A monotonous
trend of ideas is not always the case; nearly
mentioned, but that is
all paranoiacs permit themselves to be diverted at least sometimes,

and many still have other considerable interests outside of the delusion.
;
The affectivity appears on direct observation to be primarily nor-

mal. Naturally one who has just discovered that in a new place of
refuge he is also persecuted is depressed or irritated. The megalomaniac
who has just received a sign of his calling from Heaven or the presi-
dent feels well satisfied. But this corresponds to the normal affective
reaction as far as the affect alone is considered. It is said that the
know that this is true in the ordinary
patients are irritable; I do not
sense. The normal person also is irritated by incessant annoyances,
on the average much more than most of these patients, who tolerate
a remarkable amount of disagreeable things. Then there are para-
noiacs who were already irritable before the disease broke out which
is therefore not at
all the cause, perhaps, however, the result of the
temperament. But one also finds calm dispositions among paranoiacs

I have not as yet seen any sanguine dispositions.
Paranoia is said to destroy morality. Strictly interpreted, that is
not the case. The moral feelings as such are not touched. But the
whole morbid logic is so one-sidedly influenced by the delusion that
the patients often cannot either 4ecognize or feel the just rights of
others. Furthermore, their own cause is so very much the only im-
portant, I might say the only sacred, thing in the whole world, that
a few lies and acts of violence also disappear in the face of it, and
are furthered and sanctified by the great purpose.
An inner classification of the paranoia forms can as yet be made
only according to the content of the delusion,^*^ which is naturally
again conditioned by the natural disposition and other internal and
external presuppositions. The forms most frequently met by the
physician are those involving injury, which again are divided into
delusions oj 'persecution, the commonest form, paranoid litigiousness,
and delusions of jealousy.
The persecuted one sees hostile people who will not let him advance
in life because of jealousy or any other selfish reasons. At the same
time they bother him, slander him, deprive him of his positions, try
to poison him (no physical persecutory delusion). Wherever the
patient goes, he is met again by persecutors, disguised or not, or at
any rate by the results of their work, in the form of letters, incitation
of the people in the neighborhood, or expressions of contempt.
The litigious paranoiac has as a rule at some time lost a law suit,
or at any rate as a result of it has not quite obtained his rights as he
expected. He now tries again, loses once more, goes to every higher
^*Â natural systematization would have to be based, in the first place, on

the peculiarities of disposition on which the paranoia is founded and then on
the reconstructing psychical mechanisms.
court but is not satisfied even by the last, but again finds reasons to
enter upon a new method of trial. At first they are ordinary causes
of action, but then new material motives are added: On the one hand
the judges will not stand for everything, respond with penalties against
the accused, let unjustifiable complaints lie, or do not investigate the
way the patient expects. On the other hand, the latter becomes irri-
tated, accuses the judges and finally all officials that have dealings
with him of prejudice, violation of the law, and conspiracy. He de-
nounces his own lawyers and those of his opponents, whereupon an
action is begun by the other side. Thus the material is far from
being exhausted; on the contrary, it is constantly increasing until
commitment or a guardianship gives the judges rest, at least for a
while. Whatever unpleasantness occurs to the patient is felt as a grave
injustice which the whole world must set right or avenge. What
they themselves do to others they do not notice at all. The worst
scoldings and slanders from their own side they cannot evaluate
and are completely astounded and indignant when the opponents react
to them. In their logic the laws contain almost only what can be
^jturned to their advantage. What is characteristic here is that from
the one case all others invariably originate. With this the litigious
paranoiacs are usually not only clever pettifogers, but they also
acquire an extensive knowledge of the laws, which to be sure they
interpret one-sidedly. Whoever, after wading through countless tons
of documents, makes a slight mistake .in an opinion or in a report,
may be sure of being attacked by them because of it.
The litigious delusion may appear in organic connection with a
purely paranoid system of delusion and in this way give proof that it
should not be separated from paranoia: A mechanic, fifty -three years
old, sued for divorce from his second wife, who was a drunkard, and
won his case. In describing a scene with his wife, who irritated him,
he had used an expression in court that anyway he was a "bad actor."
In the judgment, in translating the slang expression into more elegant
diction, it was stated that he had himself admitted that he was a
"brutal man," and from this it was inferred that the wife alone was
not altogether at fault and that he should contribute to the cost of

""action. The expression angered him and he demanded a reversal of
the judgment; he did not recognize the divorce at all, visited his wife
repeatedly in a demonstrative manner, went through all possible and
impossible appeals, denounced the authorities, neglected his work and
finally made considerable debts. Thus he had bought a suit with the
assurance that it would be paid for, then he himself instigated the
dealer to press him for the money on being
; pressed, he proposed the
;
courts, and when the creditor came to him to attempt to obtain a

friendly settlement, he threw him out of the house. Thus the patient
had to be brought to the hospital. He was a jovial, fundamentally
really a good-nuturcd man, who would like to have succeeded a
little better in the world without, however, having the strength to
accomplish this (the usual inner discord of the paranoiacs). In one
respect, to be sure, he had accomplished something; "he, the simple
laborer," had been able in the town meetings and at the elections to
have his opinion prevail against respected citizens but he still re-
mained the simple laborer while one of his opponents rose to th^
highest position in Switzerland; another achieved the second highest
position (painful wound to his vanity). Toward his wife he had the
attitude of the drunken husband. In reality he still loved her; on the
other hand, she conducted herself in such a way that he had to obtain
a divorce, and in spite of his age he thought of a better marriage
(second conflict). Hence the complex sensitiveness toward the judg-
ments in the case that he won; hence the non-recognition of the divorce
he himself asked for. In his consciousness, to be sure, the reason was
different. His distinguished political opponents want to revenge them-
selves on him; they induced the judges to render such a decision so
that every woman who would like to marry him would have occasion
to inquire of them concerning his brutality, and so that they could
thus lower his standing and hinder him in remarrying. But as the
man was euphoric and not distrustful, his delusion developed in a
somewhat unusual As he had everywhere been treated with
direction:
noticeable indulgence, even when in his actions and in his incurring
debts he over-stepped the bounds, his opponents did not really mean
to do so badly by him, or they wanted to prevent their part in the
matter from being exposed in court. Therefore he believed that behind
his back they paid all his debts, and in order to try them again and
again, he made debts, sold his furniture that had already been put
up as security, etc.
The jealous patients are probabty for the most part womea (alco-
holic jealousy delusion does not belong here). They find evidence
everywhere that their husbands deceive them with many other women
with the old laundress as well as with the beautiful daughter of the
neighbor they have affairs, give them money, etc.
Hypochondriacal delusions also are said to occur in paranoia; as
yet I have not seen them.
The forms of delusions of influence are never wholly free from an
admixture of more or less pronounced ideas of grandeur. All such
patients have an exalted feeling of self-importance; they consider
524 TEXTBOOK-OF PSYCHIATRY
themselves extraordinary in some particular line. The persecutory
delusion is partly connected with it, because they arouse the envy of
others whose path they cross, etc. On the other hand, where the
grandiose delusion dominates, the feeling of persecution is only rarely
lacking; sometimes, especially in erotics, it approximates the main
delusion in significance.
Among the megalomaniacs we must first mention the inventors who
appear in every branch of mechanics. Often some of the ideas are
not at all bad, but some weakness in their planning is overlooked
while it is just on this that the entire failure depends. Before Zeppelin
and the Wrights, dirigible airships were decidedly favorite objects of
invention a half century earlier it was perpetual motion.
;
-^ Allied to the mechanical inventors are the discoverers in all scientific

fields. Here one already sees more frequently confused things.
Entirely free in their combinations are the prophets in religious and
political fields nvho often find many followers and obtain a certain
amount of importance (Illustration: Lomhroso, The Man of Genius).
With these probably should be classed the above mentioned mul-
tiple murderer Wagner. Potapkine, who infected pretty nearly the
entire population of his village (in the province of Orel, Russia) with
his teachings about a return to a primitive state, or at least influenced
them so that numerous punishments for anti-religious acts were
administered.^*^
The geneologists or interpretateurs filiaux of the French, the para-
noiacs with the delusion of high descent, realize the everyday dream
of so many children, which has also found expression in the fairy tale;
they have merely been stealthily handed over to their poor parents or
given to them to bring up in reality they are children of the nobility
;
but for some fantastic reason, made more or less plausible, they are
not brought up in the circumstances to which they were bom. Only
a certain time or event is awaited for them to be returned to their
proper social position.
The erotics believe themselves loved by persons of the opposite sex
of higher rank, often of the highest; they pursue him with every pos-
sible kind of messages that they are ready for the honor, or they enter
his residence by stealth or force, where they demand to be treated as
husband or wife. That they do not succeed in this is naturally due
to the intrigues of others, to wickedness which is usually thought out
more or less definitely in detail in the paranoic manner.
All these forms are markedly egocentric; the entire delusional
system turns about the patient, his wishes and his fears. But other
**' Monatsschr, f Kriminalpsychol. II. 1905/1906, S. 493.
forms can also be thought of. Tlius I know a minister who for many
years has the delusion that the children of his neighborhood are
maltreated by their parents. From what I know the case can only
be brought under the head of paranoia. The delusion would be com-
prehensible if one supposes that the patient suffers from repressed
sadism or masochism.
The course of paranoia is always most chronic. Some of the
patients, but not all, were on closer inspection noticeable even earlier
for selfishness, misinterpretation of the acts of others, and sensitive-
ness. The prodromal stage is practically never observed by physicians,
ând the relatives also can usually give no good account of it, as the
patients at this time are nearly all inclined to be very reticent. For
the customary descriptions in the books the paranoids much rather
than the paranoiacs have served as models. No dependence can be
placed on the statements of the patients themselves because just in
these connections they are deceived by a vast number of memory
illusions. At all events many cases require a greater number of years
to develop, in that the persecuted at first become only distrustful and
""are still capable of recognizing at least a kind of uncertainty in their
conclusions, but after a while there comes to them the certainty which
is then never lost. Similar is the case in many forms of grandiose
delusions, whose haughty over-estimation of self and of their secret
hopes are slowly and easily hatched out as ideas of greatness. But in
both kinds an "illumination" can suddenly permit the disease to
become manifest. In litigious patients it is usually to be dated from
the first court decision ; but the delusions and the entire litigation are
usually developed completely only in the course of years.
Paranoia frequently breaks out first in later manhood according
to Kraepelin in two thirds of the cases after the thirties but there
are also cases which become sick around the twenties.
In all forms, periods (usually long ones, lasting months and years)
of stronger delusional formation and corresponding reaction alternate
with quieter phases, in which the patients are more capable of getting
along with other people and of being active in their calling. Most of
these excitations and mitigations seem to come from within outward;
others, chiefly in the persecuted, are connected especially often with
a change of residence, after which the patients at first feel safe; but
after a while the old delusions become attached to the new surround-
ings; often a letter that the patients have written produces the change.
They considered themselves concealed; now^ their address has become
known through the addressee or through the indiscretion of the postal
authorities, and the chase begins again. Thus many travel from
place to place during their whole lives, always going as far as possible
from the one and in this way get all over the earth.
just inhabited,
In the insane asylum at Washington, I was told that the capitol of
the Republic especially attracts paranoiacs from the whole earth
because they expect help from the President of the United States.
There is surely no cure for paranoia. Those cases described in
the literature of the subject can without doing them violence be con-
sidered as schizophrenia; least of all the case of Bjerre.^** On the
other hand, improvements appear with age, either because the patients
finally come to see that they carry on a useless struggle, or because
during the involution the energy declines, so that they are less active,
and because of their passivity get along better with those about them.
Conduct. As was said, most paranoiacs during the years of incuba-
tion are
more or less reticent more expansive characters with an
inclination to delusions of grandeur may be exceptions. At the height
of the disease we have to keep distinct how they conduct themselves
in their ordinary businessand social life, and how they carry on their
delusion. Conduct is about normal as far as it is not influenced by
the delusion. The degree of influence varies greatly from one patient
to another. In the one the delusion takes up the largest part of their
time and interest; almost in every social gathering some partial delu-
sion crops up and makes the patients noticeable. At the other extremes
there are calm, quiet natures that continue to work in their calling even
though with difficulty; they change their place of residence now and
then or do something else incomprehensible on the outside, but they
may remain unnoticed by most people, sometimes even by those near
to them; but in the same patients also the conduct changes as a rule
in the course of months and years.
Within the limits of non-paranoiac activity the patients conduct
themselves normally. They never lose control. But in the pursuit of
their purposes they also conduct themselves on the whole like other
people who would have to achieve a similar object. Prophets, to be
sure, often indicate their mission by appropriate dress, hair and beard.
But most of the patients are extremely inconspicuous. Real excita-
tions which would be pathologic in themselves through their severity
and through the disruptions of the train of thought occur, if at all, only
as brief episodes. On the other hand, many of the persecuted, for
comprehensible reasons, are ordinarily cranky, irritated, and irascible.
In the pursuit of their aims nearly all show a certain, often a high
degree of passionateness. Many persecuted patients react with eva-
^ Zur Radikalbehandlung der chronischen Paranoia. Jahrbuch fiir Psycho-

analyse usw. Bd. III. S. 795.Deuticke, Leipzig and Wien.
.
sion, threats, scolding, insulting letters, and appeals to the authorities.

Those from grandiose delusions often use the press in a pro-
suffering
lific manner. In general many paranoiacs actually become "grapho-
maniacs." Actively persecuted patients readily become persecutors
(persecutes persecuteurs)
If the patient can no longer resort to legal measures, he seizes on
"self-defense," either shooting his opponent, or, not rarely, assaulting
a distinguished person in the hope that publicity will compel an
impartial investigation and thus at last bring the true facts to light.
In rarer cases, in improvers of the universe and prophets, acts of
violence belong to the delusional system, as in the Wagner case; the
religious paranoiac David Lazaretti died in 1878 in a battle with gov-
ernment troops.
Frequency. In hospitals, paranoia is a very rare disease, so that
some psychiatrists doubt its existence; not one percent of admissions
can be assigned to it. But outside it is not such a great rarity. It is
always some special occurrence (an assault, a trial) that brings the
patients to the psychiatrist. --
According to Kraepelin, paranoia chiefly afflicts men (70%); my
experience also coincides with this.
The diagnosis of paranoia is not always at all easy in practice. The
patients know which of their ideas are considered morbid by others
and can conceal or weaken them so that they can be defended. The
delimitation in principle from mere psychopathy is often absolutely
impossible where the delusion^lhas centered itself on a class of ideas
that are beyond proof, as in the case of founders of religion, politicians,
and philosophers. Indeed, one can even enter into disputes concerning
the morbidity of scientific discoveries and mechanical inventions that
are entirely new, even if so many real inventors were not considered
"crazy," as far as they are not really sick in some wây. For even
a crazy man may sometimes invent something worth while. jMoreover,
an idea may, by chance, correspond with reality and nevertheless be
a delusion.^^^ For the diagnosis two things must be considered:
1. The logical proof of the idea by the patient, which in the morbid
cases shows incorrectible mistakes in the premises as well as in the

logic, to the extent that certain parts of a discussion are inaccessible,
and important and self-evident counter arguments simply cannot be
appreciated. But with this, the momentary affective state and the
"' It happened that a paranoiac believed himself poisoned with corrosive
sublimate and corrosive sublimate was really supposed to have been found in
the beer in the chemical laborator\', because, as was ascertained later, the
reagents were contaminated.
patient's general intelligence must be taken into consideration. The
affect accounts for defective logic in normal people also, and a weak
intelligence even without paranoia will not be able to grasp complicated
relations.
2. The cancer-like extension of the delusion to ever widening areas
and the far-reaching domination by the delusion of the entire per-
sonality in its behavior and its strivings. Some one may write a
proof as convincing as it is disputable that the seat of the soul is in the
sympathetic system; but he is not a paranoiac as long as he does not
ascribe an abnormal significance to this "discovery" and does not find
new evidence for it everywhere where none is to be found. The indi-
vidual ideas of reference and the memory illusions, even when according
to their content they are possible, often prove on closer inspection to
be distinctly morbid, inasmuch as what corresponds to the delusion is
often carried out with utterly impossible definiteness and impossible
details, while what does not belong to the delusion is not related at
all, is not even perceived by the patient, is not experienced, and on
demand can be supplemented only in a defective, unclear, and uncertain

manner.
Anatomical findings that might belong to paranoia have not been
found.
Limitation. The litigious paranoiac can usually be readily dis-
tinguished from other litigationists by his immovable consistency and
especially by the circumstances that all his complaints can be ascribed
to the first unfortunate litigation. The paranoid is usually recognized
easily by the and the inner con-

logical impossibility of the delusion
by the hallucinations, the disturbance of the affect,
tradictions, then
and by other schizophrenic signs. Only in case of a very furtive
beginning can these peculiarities be so little developed that one is in
doubt for a while, or even incorrectly diagnoses paranoia. The manic-
depressive delusional forms can be recognized first of all by the affective
disturbances, the flight of ideas or the retardation of thought, by the
inconsistency of the delusions and by the entire picture. The not
very rare belated forms of paranoia are to be differentiated from the
senile paranoid forms by the strong, consistent delusional system, and
by the absence of symptoms that indicate cerebral atrophy. There-
fore the differential diagnosis i% in paranoia also a negative one: Delu-
sional systems, besides which no signs of another disease can be found,
are to be considered paranoic.
With these differential diagnostic observations the delimitation of
the morbid pictures is at the same time essentially disposed of.
"Abortive" cases of paranoia are supposed to have been seen.

(Gaupp.)^'^'^ Now there certainly are katathymic delusional forma-

tions that correct themselves. But I would not call these diseases
paranoia because a proper demarcation of the concept is attained only
then when the incurability, which is an important sign of nearly all
cases, is included in the denotation of the concept. The abortive cases

probably also lack the important sign of the general extension of the
ideas. Some of the abortive and "milder" paranoias (Friedmann)
are probably mild manic-depressive delusional forms. The "periodic"
paranoia belongs partly to our schizophrenia, to a less extent to manic-
depressive insanity.
The paranoia completa (Delipe chronique a evolution systematique
of Magnan) belongs to the schizophrenia group (paranoid or
paraphrenic).
The alcoholic paranoias are toxic psychoses sui generis, if they
exist at all, and are not to be included in the paranoid groups.
The formulation of a paranoia originaria (Sanders), which is said
to begin in childhood, is probably based on the mistaking of memory
deceptions.
There are besides paranoia-like diseases which as yet have been
too little observed; they are perhaps involutionary diseases; there is
also the delusional formation in those hard of hearing,^*" and in oligo-

phrenics: Many feeble-minded only come to the asylum because of
the development of ideas of persecution, which are not quite sys-
tematized but which also do not degenerate to the complete nonsense
and the symbolic foolishness of schizophrenia. Usually, but not
always, there are hallucinations of hearing at night, sometimes also
those of sight, rarely of the other senses. It does not go as far as the
catatonicsymptom complex and just as little to a severe progressive
dementia. The affective rapport especially is preserved; the patients
also retain their external bearing in so far as the direct reaction to
the persecutions in the form of attacks of rage and scolding does not
make them unsociable. Occasionally also disconnected grandiose ideas
appear besides, or in place of, the delusion of persecution. It is not
improbable that this is a case of paranoia upon which the oligophrenia
puts its particular impress, in that it prevents a logical development
of the delusional system. But with this conception also the diflficulty
from Pjropj -paranoid remains.
of differentiation
Conception of Paranoia. The delusional system of paranoiacs is a
psychic formation that gives the appearance of a simple exaggeration
"'Ueber paranoische Veranlagung imd abortive Paranoia, Zentralbl. fur

Nervenheilkunde und Psychiatrie 1910, S. 65.
"'See p. 533.
;

of normal processes.^^^ The normal individual reacts in the same way
but not continually so. Everybody has false references to oneself as
well as insufficiency of logic as soon as he is in an affective state.^*^
The manifestation becomes pathological only because it cannot be
corrected,and especially because of the tendency to spread generally,

and the unintermittent continuous working of the affective mechanism
once put in operation. The only known symptom of paranoia, the
J
delusional formation, proves to be a reaction form to certain external
and internal situations. At all events, it is not a direct result of any
process in the brain or of a constitutional degeneration, and one must
assume that at least in the milder cases the disease would not have
broken out without releasing an external situation, or at least would
not have assumed the same form. For the origin of the disease deter-
mines the symptomatology in manifold ways.^^ To be sure, one will
presuppose that here too there are such serious dispositions that even
everyday and unavoidable difficulties would have set free the disease
such patients under any circumstances become paranoiacs, while
others become sick only in the face of serious conflicts.
Invariably we see at the root of the disease a situation to which
the patients are not equal and to which they react by means of the
disease: The young man feels in himself the impulse to achieve and
be something worth while, but because of an intellectual or especially
characterological weakness he does not get as far as he would like.
He is not sufficiently indifferent to ascribe the failure to fate and to
let it rest on himself; still less has he the strength to admit his own^
mistakes to himself and make them clear to himself. Then according

to the everyday method he blames the environment and merges into
the delusion of persecution, or in case of a more cheerful disposition
he fulfills his wishes in phantasy and works himself out of reality into
the delusion of grandeur.
The young woman who wants to get married but who lacks the
natural instinct to love and attract a man finally thinks herself loved
without any action on her part, and as in the fairy tales devised for
children supposedly sexless, she is loved by one who at the same time
brings her promotion in rank (which is obviously felt as the chief
thing). Since reality cannot be shaken off altogether, here too ideas
of persecution are usually added, while besides the real delusion of
persecution the ideas of greatness persist, unclearly and perhaps gen-
*"
That is the reason why not only in practice, but in principle also a sharp
line between paranoia and the normal and mere psychopathy cannot be drawn.
"" See p. 95.
^^ Comp. above the illustrations.
erally undeveloped, as mere efforts toward greatness. Thus there is

probably no paranoiac (and paranoia-likej delusion of greatness
without delusions of persecution, and no delusion of persecution with-
out ideas of greatness or at least aspiration to greatness, and the dif-
ference between the two forms becomes relative. I therefore believe
I may here include the delusion of grandeur in the consideration,

although it has as yet been very inadequately investigated. The "ex-
alted feeling of self" which is ascribed to paranoiacs of various kinds is,
therefore, probably a necessary condition for the origin of the disease.

But I should like to add that according to everything I know, this
feeling must be opposed by a feeling of insufficiency, probably re-
pressed, before the paranoia can originate. Whoever collapses with-
out this inner conflict has no occasion for a delusion of persecution,
and also probably cannot produce the energy to separate himself
from reality. The multiple murderer Wagner himself felt the
diflEiculty of his situation and expressed it in a remarkably correct
way:
"You will therefore understand when I go into ecstasies over the
man who is robust in body and soul, when the strong, the indifferent,
the fighters, the criminals and the beasts impress me. I think of them
all CIS the opposite of myself. In this writing I am not using what
I have read, as I am in general a very independent spirit. I wâs not
tempted by the 'fashionable philosopher,' and on this occasion I want
to remark to the Nietzsche followers that the key to a comprehension
of his writings is weakness. The feeling of impotence brings forth
the strong words, the bold sounds to battle are emitted by the trumpet
called persecution insanity. The signs of the truly strong are repose
and good-will. The strong man, about whom we palaver in our litera-
ture, does not exist. Furthemore, there is no such thing as the strong
man tamer of the populace. The strong individuals
in the role of a
are those who without any
fuss do their duty. These have neither the
time nor the oecasion to throw themselves into a pose and try to be
something great."
It is probably not an accident that in all closely observed para-
noiacs, all of them persecuted, I found a peculiarly weak sexuality
which may point to an insufficiency of the impulses generally or to
inner inhibitions.
The would therefore consist:
disposition for paranoia
1. in a very
dominating affectivity which, however, in contrast
with the hysterical disposition, is persistent and stable and
2. in a strong feeling of self which, however, is opposed by some
inferiority, and
;

3. in external difficulties that increase or provoke this inner con-
ffict (which probably wanted to be repressed)
4. there must exist a maladjustment between the understanding
and the affectivity so that in certain matters the latter obtains the
lead. But this maladjustment without the other peculiarities would
only lead to katathymic delusions or hysterical moodiness, etc., but
not to paranoia. Many investigations are still needed before we can
see more clearly. But at all events there is not merely one but several
dispositions that correspond to the above conditions and out of which
the picture of paranoia may grow.^^^
The disposition for paranoia does not have to be the same as the
"paranoid character," which likes to relate the actions of the environ-
ment to itself and interpret them in an evil manner and with this
seriously undervalue the rights of others as against its own.^^^
Ferenczi finds the causes of paranoia in the repression of homo-
sexual impulses; his line of proof is, however, altogether insufficient.
Formerly the French included paranoia among the monomaniacs,
in the belief that there was involved a very circumscribed disease of
the psyche. A debate as to whether or not monomaniacs exist is
useless, as it depends on the conception, while in this case the facts
are fairly clear. Likewise there is no sense in discussing whether
the intelligence of the paranoiacs is retained because outside of the
delusion they think correctly, or whether the patients are demented
because in the delusions they produce nonsense and cannot correct it.
^ Behind the paranoia there was also supposed to exist a process

disease (brain degeneration). In favor of this could be mentioned:
1. the not rare appearance of prodromes, before the releasing and
symptom determining situation takes place, 2. the incurability and
unyieldingness of the delusional system. 3. the beginning which
usually takes place in advanced age, and 4. the remissions and
exacerbations occurring from within independently of conditions. But
for the incurabilitywe have an example in the traumatic cases of how
psychogenic causes when they are permanently effective produce a
lasting morbid picture furthermore, in the expectation neurosis which
;
does not become cured without treatment. In an analogous way one

can make it at least probable in paranoia, that the causes, the inner
and outer splitting, cannot be removed. That the disease frequently
appears in later years could be caused by the fact that only then do
these conflicts become definite. The youth may always still have
"' Comp.
also p. 177.
Carriers of the paranoid character are psychopaths of various kinds, but
^'^
especially frequently latent schizophrenics and blood relations of schizophrenics.

hopes of getting up in the world, even though here and there he has
failed. And the fluctuations from within require a still more exact
confirmation, as perhaps external factors or purely psychogenic re-
sults of the inner "elaboration," of understanding oneself, can none
the less determine such changes. There are cases of delusional forma-
tion similar to paranoia that run quickly into a cure which, however,
^^^ come
do not usually to the physician's attention. Because when
only transient and chiefly exogenous reasons are present, they must
become cured before the deception develops into a disease.
Treatment. Nothing can be done for the disease. One has to make
the best of it. Some of the patients are best left to themselves. The
more one wants to help, the worse it is. One must interfere when
they become violent or waste their fortune, in the former case by com-
mitment, in the second case a guardianship may suffice at times. When
possible one should avoid protracted institutional treatment because
this only makes the patients all the more embittered against the whole
world.
2. The Delusion of Persecution of the Hard 0/ Hearing

The hard and the deaf and dumb frequently do not
of hearing
sufficiently understand, those about them, consequently they become
irritable and distrustful and, with or without excitement, they come to
false conclusions about the environment. In some cases, especially in
elderly women, this develops into a more connected paranoia-like
morbid picture, usually with ideas of persecution which rarely, how-
ever, attain full certainty and show more the character of anxious
apprehension. Memory deception, illusions, and occasionally prob-
ably also hallucinations, confirm the delusion and increase the
difficulties.
The disease runs a chronic course with fluctuations and is incurable,

although through skilfull behavior of the environment it is still
amenable to influences.
Allers observed similar cases among prisoners of war, who could
not understand the language of their environment. It is significant
that here recovery took place as soon as the patients understood and
were understood.
3. Litigious Insanity
Litigious insanity is in the first place a syndrome, which occurs

in various diseases, such as schizophrenia, manic-depressive insanity,
*" Comp. p. 529 Friedmann, Gaupp. I myself know several typical inter-
mediate cases of this sort.
certain abnormal character dispositions, and also in paranoia. If one
simply speaks of litigious insanity, the paranoiac is meant by it. In
spite of the fact that this form of paranoia shows some peculiarities
when compared to the others, I prefer to adhere to Kraepelin's former
conception and treat it with paranoia, not only because of the inner
connections, but also in order to avoid double description of the very
numerous common features in both morbid groups.
4. Induced Insanity (Folie a Deux)

happens that paranoid or paranoiac and rarely hypomanic pa-
It
tients not only can make those with whom they live close together
believe in their delusions, but they so infect them that the latter under
conditions themselves continue to build on the delusion; at all events
they remain blind when confronted with the contradictions from
reality, they have the same deceptions of memory and eventually even
illusions and hallucinations as the one who became afflicted first, and
pass through paranoid or hysteroid excitements. This is called induced
insanity.
But the individual followers of a prophet who represents an un-
demonstrable view will be declared insane only in the worst cases,
although usually none of them can be considered responsible or capable
of action in matters connected with the induced view.
The primary inducing patientis in such cases an energetic char-
acter. Those induced are mostly his blood relations, more rarely it
concerns husbands, which throws light on the significance of familiar
dispositions. They often take active part in the development of the
delusional system, also enhance one another in the development of
symptoms (the same psychological process as in cumulative crimin-
ality). But above all they cooperate in the morbid reactions to the
outer world, such as the querulousness, cursing or violence, or they
withdraw together, restricting contact with the world to the most
necessary minimum.
Through timely interference, i.e. a separation from the diseased
focus, most of the induced cases can rapidly be cured. There are ex-
ceptions, however, which then lead one to suspect that they too suffer
from an independent disease in which only certain manifestations, like
the content of the delusion, were determined by induction.
In reference to paranoia-like epidemics, there are some showing
such hysteriform symptoms as: ecstasies, convulsions, major hysterical
attacks, chorea magna, visions, and other hallucinations of an hys-
terical character, and automatic preaching. Not rarely both series of
symptoms exist together.
5. The Reactive Mental Disturbance of Prisoners
It is only natural that some mental disturbance should become

manifest in prison; this is especially true of dementia prajcox. Some
are directly set free as a result of the confinement as delirium tremens,
in the alcoholic; others first become recognized during detention, or
break out there, as in the case of paresis where the connection between
confinement and psychosis can at most lie in the fact, that the latently
existing psychosis leads to the crime or to let oneself be detected, and
then becomes manifest in prison.
Besides these, there are definite syndromes which are directly pre-
cipitated by the confinement and carry the mark of this origin in the
course and in the individual symptoms. They naturally originate on
the basis of certain dispositions, which may, however, differ very
markedly. In some kinds of psychopathies and pronounced chronic
mental diseases, above all in schizophrenia, then in epilepsy but also
in others, the various pictures might appear, each depending on the
psychic constellations. Among other things these strongly depend, on
the situation of the imprisonment. Those syndromes which mimic
acutely an insanity, as the Ganser symptom complex, are naturally
in the first place diseases of detention pending trial, while the chronic
pictures belong to the imprisonment following the sentence.
It is not yet possible to describe all forms. The following may be
mentioned: (a), (b), and (c). Exaggerated affect reactions at the
confinement. They begin mostly soon after the confinement, partly
as an explosion of the gradually accumulated worry, and partly on
the occasion of any irritability. They manifest themselves especially
frequently in an attack of rage and cursing with blind destruction
(Prison crash), or in an anxious depression with vague delusions of
sin and persecution. In most cases these conditions pass over rapidly,
the prison crash usually in a few hours. An affective disturbance
which lasts longer and which occasionally appears even after longer
confinement is the stupor, which has an hysterical character.
(d) A simulation of insanity, as imagined by the layman, which
is controlled by the unconscious, is the Ganser twilight state,^^^ and
^^^ the puerilism seeks to represent a childish
the clown syndrome;
dementia."
(e) In long continued confinements we observe in the first place
psychogenic depressions and excitable states as a reaction to the un-
'" See p. 545.
^Bleuler, Das Faxensyndrom. Psychiatr.-Neurol. Wochenschrift, 12, Jahr-
gang 1910-11, S. 375.
"*See p. 545.
pleasant situation, to which also belongs Vischer's barbed wire disease
of war prisoners/^"
A queruloiisness with more or less prononced delusions, in
(f)
which the patients imagine themselves unjustly treated and hence

react with all plausible statements and protests, and under conditions
also with violence.
(g) One of the most frequent syndromes in long detention is the

imprisonment complex, which originates in quite the same manner
in various dispositions: Either gradually or with a sudden inspira-
tion, with or without hallucinations, the patients imagine themselves
innocent,^"^ liberated or pardoned. But as they are not liberated in
reality they develop delusions of persecution about the environment,
the public prosecutor, and the courts. The delusion attains tangible
certainty through hallucinations of the different senses, especially of
hearing,and strikingly often also of smell (poisoned gases are blown
in and taste; these are supported by deceptions of
into the cell),
memory and dreams of severe maltreatment which are taken for reality.
The participation of the two components, liberation and persecution,
may appear in very different ways. In one case one delusion dominates,
in another the other.The syndrome resembles very much the para-
noid and can only be differentiated from it with certainty by the
outcome. As a rule it disappears after the patient has been discharged
from prison or transferred to the insane asylum.
Next to the confinement querulousness Kraepelin mentions as a
prison psychosis the ''delusion of persecution with local coloring"
(regularly with hallucinations) and Ruedin's so-called "presenile de-
lusion of being pardoned," which until now has only been observed in
life prisoners after they have been confined for a long time. As the
first is mostly associated with ideas of liberation and the second with
ideas of persecution, the two states may be conceived as variants of

the prison complex, determined by different outer and inner conditions.
The presenile delusion of pardon is incurable.
Kraepelin's prisoner's insanity (Gefangenenwahnsinn) appears soon
after the the arrest, and shows a mixture of depressive and grandiose
ideas, which do not however become fixed, and a slight clouding of
consciousness. It becomes cured after discharge or after transference
into an insane asylum.
Treatment. The general prophylaxis consists naturally in a pos-
sible avoidance of conflicts and in restricting of solitary confinement,
"" Vischer, Die Stacheldraht Krankheit, Zurich, Rascher 1918.

"* Even in other cases the crime or the sentence are subsequently completely
shut off from memory.
the special prophylaxis in an intelligible consideration of the situation

and the peculiarities of the prisoners, who are all, as it were, psycho-
paths in all directions. The proiKJunced psychosis heals, in so far
as it is not an exacerbation of an otherwise existing chronic state, at
any rate in the most acute forms. Most of the others recover regu-
larly by transference in a better milieu (hospital) which takes
more consideration of the disease than of the "object of punishment."
Psychoses pending examinations, which serve the (unconscious) pur-
pose of attaining a discharge, or cessation of the trial as a result of
insanity, do not naturally recover easily during the procedures. The
most important conditions for the recovery are absent in cases of the
specific diseases of life prisoners.
6. The Primitive Reactions
Under primitive reactions Kretschmer '^^^

includes the exaggerated
or false simple affective reactions like screaming, attacks of rage,
affect stupor, reactive depressions ("homesick"), the rare manic-like
reactive states, and similar reactions. Whether one should also add
to it vasomotor syndromes and other physical symptoms matters very
little here. These reactions already occur in animals, then in chil-
dren, in insane and neurotic patients of all forms, and among the most
varied psychopaths, and what is more, they occur also in such who
in other matters, e.g. intellectually, stand very high. Like in the
prison crash, they frequently appear as independent transitory dis-
eases. Such cases are usually ushered in with deep disturbances of
consciousness with or without hallucinations. They last a few min-
utes, atmost a few weeks, and leave behind a pronounced or absolute
amnesia and full insight. "Exogenous Reaction types." These origi-
nate on the different psychopathies but only on the basis of actual
mental diseases (schizophrenia, epilepsy, organic states, etc.). As
they are relatively complicated, they can also be united into one
concept with the reactive depressions and exaltations.
7. Reactive Depressions and Exaltations

Reactive depressions, which become aggravated to a mental dis-
ease, are quite rare in the light of present views. In so far as they
come to the psychiatrist, they are mostly partial manifestations of
other diseases, especially of manic depressive insanity, and naturally
of psychopathies and neuroses. Also seniles who are incapable of
helping themselves can react with melancholic states of short duration.
Reactive manias we do not know.
^Der sensitive Beziehungswahn. Julius Springer, Berlin, 1918.
8. The Reactive Impulses (Impulsive Insanity of Kraepelin)
Various impulsive actions, which, among other things were also
described as impulsive insanity and formerly as monomanias, have
changed into reaction forms in the great majority of cases. Still one
observes externally the same acts as a result of organic brain dis-
turbances, of epilepsy, of alcoholic poisoning, and similar diseases,
and, moreover, the actual reactions sometimes act first on the basis
of such disturbances of consciousness. Others are based on psychotic
dispositions, especially schizophrenia. As independent morbid pic-
tures they develop on the soil of all kinds of psychopathies.
Those that are most frequently observed almost only among men
as states of wandering (Fugues, Poriomania) are of an epileptic
nature, or are due to cerebral traumas; others occur in schizophrenias.
Pure reactive impulses may be habitual or may appear only once in a
life time ; the latter especially in puberty.
The most common is undoubtedly the impulse to set fire (pyro-
mania), which we observe most frequently among young people who
find themselves (subjectively) in an unbearable situation, above all
among half grown servant girls, who were torn away from their own
family and can find no emotional contact with the new place. Not-
withstanding the impulsive element in regard to the main object, the
will to set fire, the pyromaniac often premeditates his act and does
it with a certain refinement, so that some are not immediately de-
tected. In such cases it mostly concerns a crime committed only

once, but it may, however, be repeated a few times, or even many
times. The perpetrators of the act cannot give, as a rule, any adequate
reason, unless the prosecutor examines it into them the act is so little;
their own that even if they are otherwise of a normal nature they
cannot even display the proper regret. The nearest explanation is the
one that by setting fire to the house in which it was unbearable for
them they wished to force some change for themselves. Regardless
^
of the fact that this could have been effected in many other ways
the explanation cannot at all be applied to all cases, e.g., where fire
is set to houses of strangers.
In some cases the unbearable situation lies in a sexual affair or
in unhappy sexual aspirations.^^^ Others experience direct sexual ex-
citements through setting or watching the fire. Alcohol also plays a
A very intelligent girl in the same situation destroyed dishes; this was
^'^
accomplished according to the Freudian unconscious manner, partly during short

attacks of fainting, until the connection became clear to us.
"" Another form of unburdening is the suicide (Comp. Jaspers, Heimweh und
Verbrechen. Diss. Heidelberg, 1909).

great part. Some set fire only wliilc drunk or durinf^ some time of
every inebriation, without showing any otlier recognizable causes. To
be sure menstruation also furnishes a disposition for it.
The act is sometimes preceded by distinct moodiness with anxiety.,
"homesickness," digestive, and similar disturbances. During the ac-
complishment of the act some seem to be in a kind of twilight state,
while others reflect and go through a conscious struggle between their
impulse and their morality. In some the impulse comes suddenly
and is at once put in operation, leaving no time for an actual reflection.
To be sure, pyromania appears in very diverse dispositions. Some
of these people do not even seem very morbid and can later lead a
normal life.^''^
More rarely one observes young servant girls who when in the
situation mentioned above kill the children entrusted to them, and
the impulsive poison mixers, likewise only of the feminine sex, who
are apparently governed by entirely different motives.
Kraepelin counts also among his impulsives some of the anonymous
letter writers ofwhich some are readily recognized as hysterical phan-
tastic persons, who at the same time find sexual gratification from their
pen activities.
More common are the kleptomaniacs, at present especially in the
form of The latter (it seems that only the feminine sex
shop-lifters.
is afflicted way) succumb to the refined stimulus of the displays
in this
in stores and steal both necessary and unnecessary articles; it would
often seem that it is done only during the menstrual period. The
kleptomaniacs in the old sense cannot even otherwise resist the impulse
of appropriating things, and here again
done regardless of whether
it is
they can make use of the things or not, they hoard them, give them
away, destroy them, and under conditions they even return them to
the rightful owners. The morality of such people may in other re-
spects be quite good. In some cases a connection was demonstrated
between the act of stealing and sexual feelings, but on the whole we
do not know the genesis of kleptomania. Disturbances of conscious-
ness and especially hysteroid twilight states sometimes accompany the
crime. One can then just as well speak of stealing during hysterical
attacks as of kleptomania.
It is quite obvious that one must guard against too frequent diag-
nosis of kleptomania. One must demonstrate not only an impulse in
the usual sense but a morbid impulse. The easiest diagnosis is made
'^Comp. Schmidt: Zur Psychologie der Brandstifter. in Jung's Psychologische

Abhandlungen. Deuticke, Leipzig- Wien, 1914, and Brill: Psychic Epilepsj', Long
Island Medical Journal, January, 1907.
in the cases where even quite useless objects are stolen, or where the
thief has made no use of the things stolen, or returned them in some
way.
As a Kraepelin mentions the buying maniacs (onio-
last category
maniacs) in whom
even buying is impulsive and leads to senseless
contraction of debts, with continuous delaying of payment until a

catastrophe clears the situation a little a little but never altogether,
because they never admit all their debts. According to Kraepelin,
here, too, always involves women. The usual frivolous debt makers,
it
who way wish to get the means for pleasure, naturally do not
in this
belong here. The particular element is impulsiveness; they "cannot
help it," which sometimes even expresses itself in the fact that not-
withstanding a good school intelligence, the patients are absolutely
incapable to think differently, and to conceive the senseless conse-
quences of their act, and the possibilities of not doing it. They do
not even feel the impulse, but they act out of their nature like the
caterpillarwhich devours the leaves.
Here one might also add the morbid collectors, who senselessly
sacrifice much time and money to a hobby and without any other
moral weaknesses they very easily get to stealing.
9. The Reactive Changes of Character

The reactive changes of character only attract attention when the
change may
be designated as an aggravation. In most cases they
appear in childhood, but may then continue throughout life unless
corresponding measures or fundamental changes in the environment
bring about recovery. But even later age is not immune to such
transformations. If one does not conceive Michael Kohlhaas as an
actual paranoiac and one wished to follow instead Kleist's description
he would be one of these types.^^^
10. The Neurotic Syndromes ^^*

A. Hysterical Syndrome. "Hysteria""^
As the hysterical symptom complex one designates the more massive
neurotic symptoms and those with conspicuous psychic connections,
'" For further details see pp. 127-128.
^" Concerning the general conception, origin, prognosis and treatment, see the
introduction to Chapter XII, p. 493.
"^ Cf the observations concerning the "Neurosen."
. pp. 493-494 f For further
.
details on hysteria see especially Lewandowsky, Die Hysterie, Berlin, Springer,

1914. For the prolific symptomatology with discussion of the older or more of
the somatic conceptions, see Binswanger, Die Hysterie, Wien, Holder, 1904.
that is to say, on the pure psychic sphere there are the psychogenic
twilight states, and on the physical sphere, the anaesthesias, hyper-
esthesias, paralyses, convulsions and contractures, the formations of
pimples and blisters, psychogenetic hemorrhages, if such exist, psycho-
genetic vomiting, and the many other analogous manifestations. In
common with the ("pseudo") neurasthenias,'"" the hysterical symptom
complex presents the paresthesias and the abnormal influences of the
vegetative organs, including that of the vasomotor system.
The psychic and the physical hysterical symptoms, e.g., a contrac-
ture and a twilight state, seem to have no direct association at first
sight. Nevertheless one can build up a useful concept only for all
the mentioned symptom complexes, for they are produced through the
same reactions in equally predisposed people, and although it is true
that the psychic manifestations can occur alone, equally directed
psychic anomalies occur next to the physical, always at least by
way of indication.
Physical Symptoms. The expression "physical" in the sympto-
matology of hysteria as well as in the other neuroses has a different
meaning than usual. In the hysterical ansesthesias it is a question of a
pure shutting ofT of incoming impulses not even from the psyche, but
from the momentary consciousness (something like in paying atten-
tion to a process, one does not perceive another) and in changed func-
,
tions of organs it is a question of the psychic influence of these organs,

like pain producing tears, shame causing blushing, and anxiety stimu-
lating the intestinal activity. In other words it is a question of things
which in other connection one calls psychic, but which are best
designated as "psychogenic physical symptoms."
Charcot has assumed that a number of physical symptoms, espe-
cially the ariaesthesias, and the absence of the palate and conjunctival
reflexes, are constant symptoms of hysteria (not of the hysterical
disposition),and he therefore designated them as "stigmata," thinking
that one can diagnose through them the existence of hysteria even if no
other symptoms were present. This is undoubtedly false. He who
is careful at the examination not to influence by suggestion seldom
finds the stigmata; however, the existence of psychogenetic anaesthe-

sias naturally proves that there is a great auto-suggestibility and with
it the possibility or the probability, that other psychogenetic symptoms
also exist.
Some also spoke of psychic stigmata and understood
thereby the psychic peculiarities leading to hysteria, especially the
affective lability but also the peculiarities of character, which were
falsely called hysterical.
'""
See p. 558.
The psychic origin of armsthesia and hypercesthesia, among other
things, is proven by the fact that they correspond in their demarka-
tions to the patient's ideas of anatomy. Thus a hand, a forearm, a
cuff, body exactly limited in the middle line, is anaes-
or a side of the
thetic; and all that, must under ordinary conditions not at all show
the consequences of ansesthesia. Notwithstanding anaesthesia and
^''
analgesia of the hand, the patients do not injure themselves and
can do delicate works. Kinesthetic ansesthesia does not give here
any ataxia; indeed, in most cases the patients know nothing of the
disturbance, until the doctor's examination calls their attention to it
(except where the anaesthesia has a direct object, as in some trau-

matic forms). The other results of stimulation of the anaesthetic
areas are very diverse, the pain reaction of the pupils remains intact
in most cases, but the reflex changes of the blood pressure can be
absent; even shock through severe irritation of the anaesthetic abdo-
minal organs may not appear. Analgesia is often associated with
slight or absent hemorrhage in minor injuries, and in raising of the
galvanic skin resistance. On the other hand the cutaneous reflexes
are mostly not changed, especially those that are inaccessible to the
Also the reflexes of the mucous mem-
will like the cremasteric reflex.
branes behave differently (the absence of the pharyngeal reflex in the
normal and in psychogenic patients seems to depend on the kind of
examination as well as on the mode of reaction of those examined).
That the symptoms may under psychic influences easily change in
intensity and extensity is quite evident from the above.
The anaesthesias may effect any of the qualities such as touch,
warmth, pain, sight, taste, etc., but not very frequently are they all
effected together. Besides neuroses, mostly monocular and with re-
tained pupilary reaction, there may occur color blindness or a nar-
rowing of color. Characteristic of psychogenic origin is especially the
"tubiform" field of vision whose surface magnitude does not increase
with the distance. Hearing is very seldom effected in peace time
hysterias. If definite boundaries are not fixed through suggestion of
the examination, the hysterical disturbances of sensibility change very
strongly in limitationand intensity as soon as one varies the tests
somewhat by distraction and various combinations of suggestions.
The local hyperaesthesias need no description. Especially to be
mentioned are the general painfulness in movements {Moebius
Akinesia Algera (Comp. Expectation Neurosis), clavus, torticollis hys-
tericus, neuralgias, vaginismus, pruritus, etc.). Some of the pains are
at all events to be traced to some sort of cramps, so also the frequent
^^ Comp. as a contrast Morvan's disease.
globus hystericus, the sensation of a ball ascending from the pelvic

region to the throat, and vaginismus. Valley's painful spots like the
hysterical zones can be suggested to the patient. The famous "ovaria"
is probably a product inspired by the doctor, even if the concerned
pressure spots seem to have certain peculiarities.
The tendon reflexes are mostly exaggerated, if they are not dimin-
ished by an accidental cause, like stupor, weakening of the legs
through long paralysis, and through similar factors. The reactions
of the pupils are normal as a rule, still one rarely finds exceptions,
which are not yet quite understood; contracted and rigid pupils are
probably based on a contraction of accommodation.
The reflexes of the skin and mucous membranes are uncommonly
changeable; anaesthetic places are not all always without reflexes.
Of motor symptoms one should mention pareses, paralyses, and
contractures. The paralyses are again not anatomical but affect
muscle groups which belong together psychically, that is, a part of a
limb, but the paralysis is especially of definite functions (as astasia
abasia, or paralysis of deglutition; with the exception of aphonia, dis-
is rare, more frequently one observes
turbances of speech (stuttering)
some sort of tics).
Of the organic functions the sympathetic and vasomotor system
(heart!) are frequently and deeply altered.
Trophic disturbances may also occur, in the form of pimples,
blisters and bleedings (Stigmatized ones) at all events there is a
;
psychogenetic fever as was demonstrated among other things by the

experiences of lung specialists who injected aqua destillata instead of
tuberculin and obtained a rise of temperature.
From the gastro-intestinal canal one observes besides the globus,
also anorexia and vomiting as favorite symptoms; but any other func-
tion may be concerned.
Lewandowsky syndromes under the name of hystero-
stresses here
philic ailments, or diseases which occur independently on an unpsycho-
genic basis, but can also originate on a psychogenic path, e.g. migraine,
epileptiform attacks, asthma, membranous enteritis, and occupation
cramps.
On the purely psychic sphere one would mention in the first place
the following permanent symptoms, which though essentially belong-
ing to the disposition are also reenforced by manifest hysteria:
Lability of the affects, moodiness, momentary reactions in all rela-
tions, with exaggerated affective outbursts in various directions. The
latter display mostly something of the theatrical; one has the feeling
that the real affective force displayed does not quite correspond to the
amount of crying and tears, and that the threat
heard from of suicide
so many on is seldom
every occasion, though often put in operation,
accomplished. Laughing and crying spells without any clear motiva-
tion are not rare. It is also remarkable how lightly, on the whole,
the hysterics carry their troubles ; in many of them it is evident that
they are actually pleased to play the part of being sick. That may
go so far that they wish to acquire real diseases,^''^ or that they are
willing to injure or castrate themselves, or permit an amputation
{furor operatorius passivus). Under certain constellations hysterics
may temporarily or lastingly appear indifferent, poor in feelings, just
like in an effective torpor.
The suggestibility of hysterics is familiar. But there was a time
when these patients were described as being particularly impermeable
to suggestions from others ; against this, they were said to be especially
auto-suggestible. The truth lies in the fact that they have a strong
positive and a strong negative suggestibility.
The attention corresponding to the affectivity is very variable. In
severe diseases the patients find it hard to collect themselves. Other-
wise it mostly depends on the interest ; in the different relations it may
be excellent or also very bad.
The memory is by the affectivity the not rare con-
easily falsified ;
nection between hysteria and pseudologia phantastica produces a

stronger similar disturbance. "Distraction," while experiencing some-
thing and also in reproducing it, will influence the function of memory.
Furthermore, amnesias are left sometimes by violent excitements, and
regularly by twilight states.
The intelligence can be good or bad. But judgment is often clouded
by the affect.
The sexuality of hysterics can be judged still less than that of
others; we see all extremes; especially among the female hysterics
there are many who are frigid in coitus or even take a negative atti-
tude to it, whereas psychosexually they may be very sensitive.
The attack like symptoms regularly associate themselves with some
affective experience, to which belong also physical injuries, especially
such as are subject to compensation. In the hysterical twilight states
the patients, in the most pronounced case, imagine themselves in an
entirely different environment, in the desert, or in heaven, theyhave
remarkable adventures, they are kidnapped by robbers or in states of
ecstatic euphoria they are received in heaven, etc. They often repeat
exciting scenes which they have actually experienced, such as sexual
attacks and similar experiences. Other twilight states fulfill wishes
*"The one who simulates, wishes to appear sick, the hysteric to be sick."
;
that cannot be granted in life, or at least exclude a great unpleasant-

ness with everything connected with it. Twilight states with discon-
nected confusions are also supposed to occur; at all events one sees
anxious hallucinatory states with all sorts of terrifying grimacing
faces and animal figures, in which logical connection cannot imme-
diately be discerned.
Seemingly pure nonsense produced in the Ganser syndrome,
is
whose sense is and whose clear purpose, to

to represent a psychosis,
the observer, is to escape punishment or at least a long sentence. Sys-
tematically the patients do many things in the reverse way; they
attempt to put in the key with the ward up or with the ring; when
it is in the lock they turn the wrong way they rub a match with the ;
wooden side or on any part of the box except where it should be rubbed
to the question, how much are 2X3
they say: 5 or 7 or any number
under 10, only not the correct one, they read on the clock 12 for 6,
3 for 9, they have two noses, etc.
Related to the Ganser syndrome is the "hysterical puerilism" which
in some inconsistent manner plays the little child and can continue for
weeks. The patient calls himself Johnny, speaks in infinitives, or
not at all, counts coins clumsily and incorrectly ; at best he counts only
the pieces but not the value ; he draws childish figures, plays the whole
day like a little child, lets himself be distracted by any triviality,
looks for his mother, and eventually states that he is 12 years old, etc.
At the same time he does also other things incorrectly and in the
reverse way, things that children would correctly understand, he does
not recognize his relatives, and shows a very inadequate flow of asso-
ciations. There may also be analgesia up to absence of the corneal
reflexes. The syndrome has thus far been described chiefly in punished
military persons.
Analogous in symptomatology, even
on account of outer condi-if
tions it is Wernicke's Pseudo-

runs a half or entire chronic course,
dementia. The patients, most of whom met with accidents, mimic
mental weakness; they are unable to answer the simplest things, the}'
rarely produce nonsense, but they do not know, or are not sure; they
use childish excuses, which resemble those of organic patients; they
do not know the date because they have not seen the calendar. To
the question of 5 X 6, they simply put together the 5 and 6 to make
56. In serial statements they easily make mistakes, they turn things
around and leave gaps. The impressibility is bad. Besides, one finds
psychogenic anaesthesias, and vasomotor manifestations; the Romberg
test is frequently very characteristic ; they let themselves fall without
any effort to balance themselves. The mood is often dull and de-
pressed. all or one must wait for it a long
Recovery does not come at
time. Since the war with accumulation of traumatic forms with
its
all sorts of variations and mixtures, the name pseudo-dementia was
extended to pictures, which besides the symptoms mentioned also show

the Ganser syndrome, psychic-apractic and many other psychogenic
symptoms. What is characteristic for all these formations aside from
the changeableness is the disappearance of the memory for elementary
knowledge and experiences, which remains intact in the organic
disturbances.
Also oriented twilight states occur in hysteria. They frequently
even months; according to character the patients are
last quite long,
different people; to be sure they follow a certain plane (e.g., stealing
or traveling; many wandering states also belong here), but without
any regard and frequently in contradiction with their
for the future
own character. At the same time they behave in an orderly way,
and correctly grasp the environment in its simpler relationships, so
that they do not always impress one as ill. In these as well as in the
clouded twilight states, thefts, arsons, and similar crimes may be
committed.
The hysterical twilight states of various kinds are often initiated
by a moodiness of many hours; they last from minutes to days, rarely
longer, and are regularly followed by complete amnesia.
Following twilight states or as equally justified manifestations
stuporous states with flexibilitas cerea may sometimes appear. We
then see somnolent states lasting from seconds to years ("Narko-
lepsy" when they suddenly fall upon the patient and do not continue
long; such attacks may also be of another nature, to wit, epileptic).
Reaction depressions, too, may occur in hysteria, but here they are
only of short duration (days, weeks) moreover there may be transient
attacks of anxiety with physical symptoms, like a choking in the
throat, and the highest oppression.
Even without the actual twilight states ideas can sometimes be-
come so vivid that they are taken as hallucinations; it mostly in-
volves visual disturbances. Where auditory deceptions occur to a
great extent without disturbances of consciousness, it is not a question
of pure hysteria.
Mainly in hysterical people do waking dreams occur, which tem-
porarily so control the patient that they have to be designated as
morbid, because they hinder him from taking account of reality.
How far purely hysterical delusional formation can go is not
yet determined; at all events, they depend on the psychic milieu.
Even in our state of society a hysteriac can imagine herself gravid,
present all signs of pregnancy, including colostrum, except the enlarged

uterus, and cause her husband, a highly regarded practitioner, to take
into the house the obstetrical nurse for a definite term. But if she
should expect a Christ as her delusional child, the patient would be a
schizophrenic if that happened in enlightened communities. In the
same way, those patients are schizophrenics who in our country or in
our times state that instead of a child they carry a toad or a snake.
One also speaks of hysterical mania, melancholia, and insanity. It
is possible that sometimes through a certain treatment the affective
relation to the environment may resemble an insanity; furthermore,

manic attacks in people who at the same time have a hysteroid dispo-
sition (hence in a combination of both diseases) run a course with
vivid visual hallucinations which remind one of hysteria, but what is
otherwise so designated and especially what was formerly so called
daily are schizophrenics according to my experience. The few times
that I thought that I had to drop this rule; I made a false diagnosis.
As hysterical attacks one describes general motor manifestations
with all kinds of movements (not spasms of individual muscles), buf-
foonry, and rigid states; the arc of a circle, supporting oneself on head
and heels, is favored. Beside the more or less incoordinated move-
ments, one frequently finds stronger or weaker hidden and caricatured
representations of any kind of experiences or wishes, so that such
attacks could just as well be added to the twilight states. Looking
from case to case the manifestations have no definite character, but
the individual attacks in the same patient may absolutely resemble
one another. They can any length of time, and repeat themselves
last
any number of times, a thousand or more in one day, but the pulse
and general condition are influenced only remarkably little.
Next to such motor attacks there are also simple fainting and dizzy
spells, which are probably due more to vasomotor origin.
Even more than in any other neuroses sleep is here xery irregular,
sometimes it is absent, sometimes very good and exaggerated, and
sometimes it comes inopportunely.

Hysterical Twilight States. 42 years a bookkeeper. Always
somewhat nervous. Not brought up by the family. Not understood
by the family, but she does a good deal for them; she is also other-
wise charitable. Her fiance died of paresis in Burgholzli shortly before
the wedding. Since then she kept up some contact with the hospital.
Lately she had to keep house for and nurse her brother, who obtained
a divorce and was also ill; she also had to care for a child suffering
from diphtheria. To recuperate, she took a trip to a friend in Ger-
many, but there got into a mess of trouble. After she had once taken
a glass of wine against her habit, she began to dig up some graves in
the cemetery, but later knew nothing about it. But she merged into
other confused states and for that reason she came to the clinic, where
at first she had attacks at different times of the day. She imagined
herself in the cemetery, heard the dead, and saw now adults and now
children. They came to her, some even into her bed, whereupon she
left the bed so as not to make it uncomfortable for them. Dead children
called to her that she should dig them up. While during her good
periods she knew nothing of the twilight states, she recalled them well
during her unclear periods. A single suggestion during the twilight
states had the effect that she could also recall them in her waking state;
to be sure, in the course of the next weeks they again lost in clearness.
Later she had an attack every night regularly between 12 and 1 (ghost
hour) Once she called the dead, telling them that they can all come,
.
the room was was room for all. Then she said:
large enough, there
"Now they are all Thereupon she went to sleep. In another
here."
attack she kept herself awake, saying that all the dead were strangers
and that all acquaintances were missing. Through one hypnotic treat-
ment the twilight states were cut short and the headaches which con-
tinued disappeared later only after many seances. The very first hyp-
nosis had been complete and deep. But after another patient next to
her was hypnotized who did not merge into deep hypnosis, it was then
impossible during this period of hospital residence to get her beyond
this stage of hypnosis. Later she had various hysterical physical
symptoms, once an hysterical torticollis; a surgeon mistook it for a
caries and wanted to apply a plaster bandage and keep her in bed for
several months, which would have cost her her position. A few hyp-
notic treatments cured it. For some years she has obtained consolation
and relative good health from Christian Science.
Hysterical Physical Symptoms. A girl, who was brought up in low
moral surroundings and was subjected to various sexual attacks, suf-
fered among other hysterical symptoms from vomiting after tasting
milk. It turned out that it originated from the fact that a stable
servant, from whom she had to get the milk, wanted to force her to
receptio seminis in ore. She had abdominal pains when she sat on the
damp grass and attributed it to "catching cold." But during the
performance of an abortion she lay on the cold grass, hence the asso-
ciation, which was revealed only on examination. She had to vomit
after the visit of a friend: the latter once related to her that she too
went through an abortion. The patient herself had attempted an
abortion with tobacco suds, after which she had a terrible spell of
vomiting. She had pains frequently in the right biceps "due to over-
work" in ironing "during bad weather": On account of masturbatic

compunctions she once squeezed her arm between the bed and the
wall. The pain really came after masturbating, with a definite com-
plex of ideas. All these and the rest of the symptoms permanently
disappeared (now twenty years) after the connection was made clear
to her in hypnosis. A part of the girl's statements could be verified
by investigation, and especially also by an examination of court
records, and without exception proved to be perfectly correct.
Hysterical Convulsive Symptoms. A nurse girl, 20 years old,
brought up in respectable surroundings. Good intelligence, but quite
early in life not frank and somewhat moody. At 12 years menin-
gitis (?). From about this time she committed minor thefts at home.
She was discharged from two places for dishonesty then she was with
;
a procureress in Paris and then got a position as nurse girl. At 17

years hysterical attacks with violence; then again muteness and even
deafness. In the night she got attacks of screaming and convulsions.
She was discharged from an insane asylum as cured after three months,
and then she was learning dress-making for five months, where she
behaved faultlessly. When she again had twitchings she came to an
aunt whom she was to help in business, but she ran about instead and
and brought home phantastic stories, how she conducted a secret bureau
under the direction of negroes, and similar tales. She stole consider-
able sums of money, formed an alliance with a young man, to whom
she told stories about having a fortune, but which, as always in such
cases, at this time it was still in the hands of her aunt, the countess.
She simulated a burglary attack and was examined in court. Then
for many days there was absolute closure of the jaws and rigidity of
tongue, which lasted 56 hours; she could, however, make herself
understood by writing; there were twitchings in her limbs. By means
of a few hypnotic treatments we definitely mastered the hysterical
symptoms (now ten years). She was a year in very strict service,
but held out bravely; then learned quickly the most important office
work and has held for nine years a well paid office position.
Ganser State. 24 years coachman. Arrested on account of fraudu-
lent security in horse dealing. After admitting participating in the
crime, he gave false answers at the examination; he did not buy a
horse, he was a servant, not a coachman, he did not know his family
name, he was not married, had no children, was 28 years old. He gave
the wrong year, and did not know where he was. On admission to
hospital he answered in the same way, but on request he immediately
gave correctly everything that he had in his pockets. Later he counted:
1, 2, 4, 7, 9, 11, etc. On the watch he mistook the big for the little
hand. He wished to open the match box by pressing on the long side,
then on the cover and the bottom and finally pushes it together. Of
interest is the following: If questioned in the tone of an examination,
one always received false answers during the twilight state, e.g. he was
not married; but when asked in a sympathetic and pitiful tone about
hispoor wife, then he was just as definitely married, praised his wife,
and told about his marriage journey, but when immediately thereafter
he was again questioned in the examination tone he again forgot
everything.
Even in such criminal cases the Ganser symptoms can represent a
shutting off of an unpleasant situation, a simulation of oneself, and
not only a simulation in the presence of the judge. After a few days
the patient became clear, but had a retrograde amnesia for the crime
and the arrest. After the latter was explained to him he attempted
suicide ;then he resigned himself to his fate.
Hysteria with Pseudologia. A 16 year old girl, mother prostitute,
father vagabond. She herself was therefore brought up by strangers.

Intelligence distinctly below the average. She was never very easy to
manage, and as she advanced in age she became more spiteful, more
garrulous, and more addicted to lying. She began to tell how she was
maltreated by various prominent people she gave so many details and
;
spoke with such conviction that five of them were detained for exam-
ination. Contradictions in her statements soon created suspicion as
to the truth of her assertions. Thus it came to trial. Here she not only
repeated the stories but added much that was new; she told how she
was maltreated during the attacks, how her ribs were broken, how the
defendants at the examination were forced to sit on iron chairs, their
hands tied to the back, how strictly every one of them was punished,
and how as a result of a complaint that she has nevertheless withdrawn
a clergyman was taken to prison on account of poisoned bonbons, so
that now he was a street cleaner. She also related how she set fire to
a house and was caught in the act, and how in the ensuing struggle
she sustained a broken leg, and she almost knocked out a woman's eye.
At the same time she modelled both the content and expression accord-
ing to the scheme of blood and thunder romances. During the exam-
ination she showed now and then hysterical absences, in which her
eyes became veiled, her look remarkably rigid, she sat motionless for
a few minutes, only to arouse herself later as from a sleep, and knew
nothing of what happened during the attack. The gynecological exam-
ination showed an old defloration. In the course of a few years she
became considerably better, although she remained sensitive and some-
times did some mischief. As she had little hope of being discharged
from the hospital because of the danger of illegitimate children, she

finally demanded continually an oophorectomy, and because no atten-
tion was paid to her, she experienced such violent ovarian pains before
each menstrual period that one had to give in, and the operation was
done under due process of the law. Since then she has been decidedly
calmer and more balanced and after ten years of internment she could
be discharged to a private family where she behaves well and earns
through work a part of her maintenance.
The Limitation of the Concept of Hysteria, although it would not
be very sharp, considering its characterization,^"'' it would nevertheless
be sufficient, if one were not in the habit from the olden times to stuff
into it so many other things, and above all things that should not be
taken into Thus one should not include in it the strong affectivity
it.
seen among savages, or the phenomena of becoming perfectly rigid

from a knock on the door, or the twilight like loss of clearness, and
similar states, or the mass epidemics (chorea Germanorum, tremor
epidemics in schools), or simple primitive reactions in attacks of rage.
Quite different are the monosymptomatic hysterias of children, where
in most cases the false connection is as important as the purpose of
the disease, the monosymptomaticwar tremors, the traumatic hysterias,
and the various psychical and physical symptoms of the peace time
hysterias.
Traumatic Hysteria, as far as our present knowledge goes, is not
differentfrom the other forms of hysteria however, in those following
;
accidents in peace time, attacks of twilight states are rarer than in

ordinary hysteria; indeed, the details of the general structure of the
hysterical picture strongly depend on the influences causing the disease,
so that relatively frequent different symptoms stand here in the fore-
ground. In injuries of peace time, attacks, paralyses and twilight
states are comparatively rare; the war brought an unfamiliar ac-
cumulation of paralyses with tremors, which are due to exertion and
fright.
Example of a traumatic hysteria without damage suit. A marked
imbecile got into a marsh from which he could not get out. Since then
he was unable to cross more open places like rooms and streets. He
feels his way by touching with his left foot forward, and after con-
siderable fumbling he slightly drags along the right foot. With it he
assumes a bent swaying attitude, balancing himself with his arms. The
disease would almost be monosymptomatic if at the same time the
patient had not given up almost altogether his active associations to
the outer world; he cares little about anything and permits himself
""^
See p. 540.
only to be fed. Perhaps that was his morbid gain. The treatment
produced very slight results.
Hysterias in children without marked change of character are
mostly monosymptomatic.
The clumsy name Hystero-epilepsy originated at a period when
epileptiform attacks were still looked upon as neuroses, and when they
could not be differentiated. Beside the ordinary epilepsies with lesser
striking hysterical symptoms, there are such who in addition show
hysteroid attacks. Furthermore, there are hysteriacs, though they are
extremely rare, who can imitate or produce an epileptiform attack.
The first is an epilepsy, the second a hysteria. What is usually called
hystero-epilepsy is hysteria with severe motor attacks, which were
falsely added to the side of epilepsy. One also speaks quite unneces-
sarily of hystero-neurasthenia when there is a mixture of symptoms
showing shades of both diseases, which naturally occurs frequently.
The limitation of Neurasthenia must start with this disease, which
analogous to its original conception, though it is not a nervous exhaus-
mimics such. He who seeks to attain the aim of the neurosis
tion, still
by representing the breakdown with symptoms that are objectively
intangible is a neurasthenic, but he who constructs the disease into a
demonstration is how the utilized mechanisms
a hysteric, no matter
differ. The war hysteric makes a permanent symptom out of his tremor
or the difficulty of hearing due to grenade shock. The environment

through too much or too little observation often causes the disease
to express itself in one concept. But above all, it is a strong personal
need for expression and a more active character with a circumscribed
feeling of inferiority in real accomplishments, which decides the
"selection of the neurosis" in the sense of hysteria. Whereas in hys-
teria all affects occur, and quite particularly a strong feeling of self,
neurasthenia always has a depressive undertone, which also manifests
itself in the symptoms (pains, hypochondriacal feelings and ideas,
sensitiveness to the extent of transient ideas of injury). However, one
is not so accurate with those distinctions in the presence of the layman.
As the name hysteria designates something notorious, whereas "neuras-
thenia" transforms the defect into something distinctive, the courtesy
of the doctor has from the time of Beard favored the latter designation
in his practice.
Much that is bad has been attributed to the "Hysterical Char-
acter"; prominently mentioned are egoism, lying, vanity, unbridled
affectivity, and lasciviousness. What is true in this matter is, that
hysteriacs are affective persons, which means that they are occasionally
carried away by the excitement of the moment. Furthermore, it may
be said that for comprehensible reasons there is a certain inclination

to make oneself noticeable in some way, which exists in the hysterical
disposition more frequently than elsewhere. As they have to play a
part, it is preferably people with a tendency to exaggeration, conceal-
ment, and lying that become markedly hysterical; at all events, in
hysteria such a disposition is and exaggerated. For the rest
utilized
the moral part of the character in hysteria can be good or bad, junt as
in other people. Side by side with the most inconsiderate egoists we
encounter among hysteriacs people most capable of sacrifice, notwith-
standing the fact that a certain impediment to altruistic activity lies
in their kind of affectivity. Pseudologia occurs without hysteria, and
even more frequently hysteria with pseudologia. Because both have a
vivid affectivity, and a peculiarity of the mental process (for the
present not describable), and because both represent deviations from
the normal, they occur more frequently together than would be the
case if it were merely accidental. For fellow beings whom they love,
hysteriacs are often capable of much sacrifice. They can, however,
also occupy themselves with an abstract humanitarian problem with
zeal and success, wherein some, to be sure, go off on a tangent
(zoophiliacs). Medically conceived, some saints are typical hysteriacs.
If a hysterical woman forges documents in favor of a charitable insti-
tution, it is in all probability vanity and not egoism that comes into
play. In certain relations Ziehen is right when he says that hysteriacs
rarely show objective interests. This is especially the case among
women, but the hysteriac has still greater need for a personal relation-
ship than the normal woman.
The necessary conditions for the Origin of hysteria can perhaps
be characterized in the following way, as far as the distinct features
are concerned: (1) under given circumstances the patient is not able
to realize his strivings on normal paths, (2) a weakness of the health
conscience determines the tendency to create for oneself a makeshift
^^
on the path leading to the disease. (3) The capacity to produce for
oneself neurotic symptoms, i.e. to produce a stronger development of
the schizoid capacity for splitting of the personality. This shows itself
in the capacity to split off,^'^ in the inability to abolish altogether
"' See p. 496.

"^The difference between the hysterical and schieophrenic splitting cannot be
described in brief. We
see it in the examination of schizophrenia. In the latter
next to the affective splitting there is still a primary or at least a splitting of
the associations, which is independent of the affects, and which e.g. may lead
to the falsification of simple concepts, which never happens in hysteria. But
even the more affective splittings in schizophrenia, which can be comparable
to those of hj^steria, are more lawless, worse determined, more massive, and
suppressed strivings, and in the coexistence of contrary strivings. Feel-
ings that are not perceived by consciousness can still be utilized by the
psyche, in that, e.g., a number called out to the patient but not heard
by him may appear as an optical hallucination. In the hysterical
twilight state one can write automatically, and even preach. The
"untrue" part of the strongly affective expressions, like in that of
schizophrenia, probably consists in the fact that split off ideas, which
are incompatible with the affect in question, continue to functionate
in the psyche and inhibit it to a certain extent, or even alter it.
(4) A strongly domineering but labile affectivity, which in a given

moment gives the mastery to one single striving and at the same time
directs the association of ideas in an abnormally strong manner in its
sense. (5) A mild manic temperament with vivid wishes, and ihe
need to assert one's personality. The difficulty of adjusting oneself
to the inner and outer circumstances, and the weakness of the health
conscience are at the bases of all neuroses (and of many schizophrenic
appearances) . The "capacity to create for oneself neurotic symptoms"
is a broader concept than that of the capacity to split the psyche.
To this belong also memories of former diseases and a physical com-
plaisance,^"^ a readily excitable vaso-motor system, conscious and un-
conscious accidentally acquired connections, ideas with reflection
mechanisms such as spasms of the smooth muscular tissue,
secretions,
trembling of the voluntary movements, etc. All these possibilities can
help to produce neurotic symptoms in general; but only in hysteria
(and neurasthenia) does the special splitting capacity play a particu-
larly big part, regardless of its close connection with the other indi-
cated mechanisms. For the formation of hysteria the labile-manic
temperament is especially necessary.
Notwithstanding all transitions Two Groups of Hysteria can be
distinguished quite sharply. In one it iswhich the
the disposition, of
most important element is the personal need for self-expression; this
gives rise to the development of the symptoms. The pronounced hys-
teriacs in the ordinary sense suffer from this form; they show the
"hysterical" or rather "nervous" and labile character also during the
times when they are free from symptoms, as well as the marked change
in the manifestations, which originate from complexes rather than
causes. In reference to the disease, it matters here very little whether
one observes today a disturbance of sensibility, or a paralysis, or an
then again not so pure and sharp as in hysteria, so that the worst contradictions
can actually exist together in the psyche. The schizophrenic psyche is infinitely
more split than the hysteric. A hysteric affect lays claim to the entire conscious
psyche; what contradicts it, is totally split off from consciousness.
"*See pp. 498-499.

attack, or a twilight state. The second type is represented by most

of the war Here the most important factor in the origin
hysterias.
is the affective event of the cause which creates a definite symptom.
It is mostly produced by the path of Kretschmer's reflex enforcement

in the widest sense, and by a desire which also needs the capacity to
produce a symptom, bring it to tlie surface, and at the same time give
it permanence. The first type occurs especially in women while the
second type in men. The forms
which association reflexes (constipa-
in
tion following enemas, blephoraspasra following inflammation of the
eyes) are the essential factor, and the aforementioned exaggerated
reactions of primitives,^^^ I would detach from hysteria, although the
transitions to it are very easy.
The Recognition of hysteria is given in the discussion above (its
differentiation from pseudoneurasthenia is not important). The most
important element is the general diagnosis of the neurosis, the psycho-
genetic reaction form, and the demonstration of the absence of another
disease in which the hysterical mechanisms cooperate (schizophrenia,
epilepsy, brain diseases, etc.), or of a physical disease which gives
cause to hysterical symptoms, as e.g. ulcer of the stomach, or phthisis.
In detail one might call attention to the following: The hysterical
attack is sharply distinguished from the epileptic,^^* if hysteria could
not occasionally give rise to a real epileptiform attack in the same way
as in the case of affective epilepsy (to be sure, this has not yet been
definitely confirmed) , or if a hysterical patient could not imitate, con-
sciously or unconsciously, an epileptiform attack, which is naturally
quite possible in hospitals. Hysteria does not follow the tonic-clonic
phases, nor the temporal limitations of the epileptic attack.The move-
ments may have any kind of character. Injuries occur only if required'
by the purpose of the disease. Babinski's sign is always absent, rigidity
of the pupils almost always. The vaso-motor system rarely coop-
erates: the pulse remains good; the attack may sometimes be followed
by an hysterical sleep but not by an exhaustion.
The strictly systematic acts in the twilight states makes the diag-
nosis of hysteria very probable, but it ismade definite only after careful
exclusion of specific signs of other diseases. One should especially look
for the many prompt reactions of hysteriacs. Wherever the twilight
state as such has a purpose, that wherever an insanity is played,
is,
the relation to the surroundings is unusually characteristic, especially

when questioned. The patient acts as if he understood nothing, but
under conditions he answers promptly, and even if falsely, the answers
"'See p. 537.
"*Comp. the latter.
;

are none the less definite, whereas in most of the other unclear states
the patient must search Frequently the patient acts
for the thoughts.
as though he does not see the examiner despite his faultless grasp of
the environment; one can quite easily notice that he does not wish
to answer, inasmuch as in spite of the fact that externally he meets
one half way, either in a hostile or negativistic behavior, he makes
no effort to grasp the questions and to search for an answer.
Like a great many others, I care nothing about the absence of the
so-called stigmata.
To the experienced physician certain hysterical types often betray
themselves with great certainty by little signs which cannot all be
enumerated; thus female patients who immediately speak of their suf-

fering with erotic smiles and elaborate the examination into a little
scene are regularly hysterical.
For Prognosis and Treatment see pp. 505 and following.
B. The So-called Neurasthenic Syndrome. Neurasthenia and

Pseudoneurasthenia
The name neurasthenia was originally taken literally. In the

form of neuroses so designated it was assumed that there was an
exhaustion of the nervous system as a result of a long continued
exaggerated activity; later the same was also assumed as a result of
normal activity in a congenital morbid exhaustibility. However, there
are exhaustive diseases; but because they do not represent neuroses
in any sense they rarely come to the psychiatrist, not frequently to the
neurologist, and even the general practitioner sees them less often
than is supposed. Overexertion and exhaustion certainly are only
rarely causes of neuroses, and never of psychoses, as the war has at
last shown to those who did not wish to see it. A general decline of
strength is no neurosis. People who toil hardest, who with a few hours
of sleep and at that frequently interrupted through attention to the
children, regularly do a day's work of 16 or more hours, year in and
year out, only exceptionally become neurasthenic. And the (pseudo-)
neurasthenics who come to the doctor have in most cases worked less
than he. What usually produces the so-called neurasthenia are affec-
tive difficulties. These can, however, become enhanced by overexertion
to be sure, one does worse in his vocation when one is exhausted; but
these are secondary matters, just as in the case of congenital exhausti-
bility of the nervous system with which one wishes to save the concept
in the everyday constitutional cases; for as soon as such patients
become enthusiastic about any idea they are able to accomplish
temporarily or persistently as much or even more than the average man.

Hence neurasthenia is iisually a pseudoneurasthenia, and only that
name should be used for it, if it were not too long.
Neurasthenia in the actual sense of the word will be discussed here,
only in order to make possible the differentiation of pseudoneurasthenia
from this side.
Actual Neurasthenia, Chronic Nervous Exhaustion

Nervous exhaustion included by Kraepelin in the activity neurosis,
ponopathies can naturally manifest itself in various ways, and accord-
ing to its nature it is also mixed with various symptoms of physical
exhaustion. Of neuropsychic manifestations one notes especially fre-

quently the following: increased exhaustibility, difficulty in psychic
activity (subjectively a bad memory), moroseness, irritable mood, and
a tendency to look upon all possible trivial symptoms as serious dis-
eases. Some of the old hypochondriacs are exhaustive neurotics. On
the physical side we find: dull pressure in the head up to localized pain,
also a feeling of physical weakness, all sorts of paresthesias, a strong
fluctuating pulse, poor appetite and imperfect digestion; as a rule,
poor sleep; one also notes besides, now this, now that symptom, all
of which have been mentioned under pseudoneurasthenia.
If properly treated, it runs a course of weeks or months, usually
with fluctuations, and ends in recovery. To be sure, relapses are not
rare, especially where the causes cannot be removed.
Besides mental and physical exertion, one may also think of insuf-
ficient sleep as one of the causes, although insufficient sleep may also
be the result of a true or false neurasthenia ; one should also consider
the predisposing factors, be they in the constitution, in physical dis-
eases, or in similar disturbances.
The differential diagnosis is especially difficult when it is a question
of schizophrenia (where, disregarding the actual schizophrenic symp-
toms, due consideration must be given to the absolute or relative indif-
ference to the future and to the treatment) of cyclothymic depressions,
,
where the exhausted patients are more accessible to soothing words

and distractions than depressive cases, of the beginning of paresis, and
of latent phthisis.
Treatment: The patient should be removed from the causative
relationships; he should take better care of himself (sleep), but he
should not be educated to worrisome self-observation and to continued
laziness; despite the physical genesis of the disease, psychic influence
is important (encouragement, and education, eventually with hyp-
nosis) .In marked excitement and insomnia moderate doses of bromide
.
S58 TEXTBOOK OF PSYCHIATRY

(15 to 45 grains) are excellent, administered every evening. To avoid
relapses, the external conditions should be regulated whenever pos-
sible; here an improvement of the affective situation is usually as
important as the reduction of the work.
The (Pseudo) Neurasthenia

Whereas the just described true neurasthenia with its physical
origins, with its preponderating physical manifestations, and its cura-
bility by simple care and strengthening no more belongs to the
psychoses than a "typhus" in which the psyche participates, pseudo-
neurasthenia, on the other hand, with its psychic genesis of the dis-
ease itself and of all its symptoms and its purely psychic suggestibility,
is as much of a mental disease as hysteria. It is comparatively more
frequent than the nervous exhaustion and represents, as mentioned^ a
definite form of flight into disease, which for itself and others shams
(unconsciously) the nervous breakdown, and for that reason shows so
much resemblance to the exhaustion. Concerning the special neuras-
thenic mechanisms one should particularly mention the marked inner
conflict in decisions and in work, and to be sure the too early insertion
of the exhaustion valve (one feels exhausted even before it is
necessary)
The following are its most important symptoms: psychic and
sensory irritability, fearfulness, inability to concentrate, forgetfulness,
persistent and transient states of anxiety, dizziness, insomnia, paraes-
thesia, topoalgias, headaches, often with pressure in the head, muscular
weakness, tremors, occupational cramps, all kinds of digestive dis-
turbances, sometimes also bulimia and polyphagia, constipation,
eventually with membranous colitis, pollutions, spermatorrhoea, ejacu-
latio prsecox, impotence, particularly frequent and almost never
lacking are cardio-vascular symptoms like abnormal irritability of the
heart, tachycardia, congestions, hyperaesthesias, etc. Although not con-
stant, the mood is nevertheless mostly depressive, and the idea of the
disease and its symptoms is always of a depressive tone.
Depending on the preponderating symptom complex, it was cus-
tomary to distinguish psychic, motor, dyspeptic, angioneurotic or
cardiac, and sexual forms, to which may be added the etiological group
of the traumatic forms; many authors add also the phobias to
neurasthenia.
The causes were already alluded to in the general observations.^"^
The extent of the cooperation of sexual excesses, especially onanism
and coitus interruptus, and to what extent that takes place on psychic
"' See p. 493, etc.
paths, is not yet quite clear. To be sure, depleting diseases can on

the one hand instigate the flight into the disease,
and on the other
hand can indicate the sensations, the exaggeration of which may
it
evince the actual morbid picture.

In the diagnosis it is necessary in the first place to exclude a
physical disease; here one should think also of tuberculosis, lues, and
poisons like CO, which produce similar pictures. Paresis and schizo-
phrenia should also be excluded. The depressive phase of cyclothymia
is mistaken by many for neurasthenia. The man who makes many
notes, who is always afraid that he did not tell the doctor enough, or
that his reports were too incorrect, is mostly a neurasthenic; for the
disease would have no sense if it were not important.
The prognoses are very different; they depend on the individual's
disposition and on the possibility of removing the outer and inner diffi-
culties even after the treatment is over. The "constitutional" forms,
who were incapable from youth to adapt themselves to reality, natu-
rally present a difficult prognosis; others who did not know how to
help themselves for the time only can be permanently cured by a few
suggestions, or encouragement, eventually through the explanation
that their fear of the results of onanism are unfounded.
The treatment does not differ in principle from hysteria, although
"tonic" measure may here exert a somewhat better suggestive force,
and in mixed forms with real exhaustion may have a direct causal
effect."^
C. The Expectation Neurosis
Following one or many bad experiences in any kind of event (read-

ing, writing, swallowing, urinating, after having been dazzled by a
strong light, or surprised through a loud noise, etc., into infinity),^"
the patient predisposed in this sense becomes dominated by the idea
that he can no longer accomplish the function in question, or that he
must suffer pain through it, and this idea becomes a reality. This
results in paralysis of a definite complex of movement, cramplike addi-
tional movements, or painful parsesthesias. Besides speech stuttering
which under conditions should be included in this category, one notes a
number of other forms of "stuttering" (stuttering in wâlking. writing,
urinating, etc.) psychic impotence naturally also belongs here, likewise
;
Moehius's akinesia algera. I would also add to it the numerous gastric

"" See p. 506.
^"The expectation neurosis can also be a relique of a physical disease, e.g. an
organic paralysis of deglutition.
neuroses, where the patient cannot tolerate certain foods and avoids
them until his menu card becomes reduced to an intolerable minimum
or to the point of starvation, and then
through energetic advice
finally
he allows himself to be convinced that he can eat everything as a
rule with good success. Unfortunately it is not rare to find an ex-
pectation neurosis as a result of a pessimistic statement of the doctor.
The expectation neurosis usually develops slower than the traumatic
neurosis, to shows a certain resemblance, and also cannot be
which it
sharply differentiated from many hysterical syndromes. However,

there are characteristic developments thus, for example,
; the stuttering
in walking in contrast to the hysterical abasia: the expectant neurotic
can still make an effort to walk, but he then becomes lame or gets pain,
whereas the abasic patient is altogether incapable of attempting to
walk. Moreover, the expectation neurosis has a "monosymptomatic
circumscription," which also expresses itself in the frequent return to
full normality after the syndrome is cured. Sometimes it is also
difficult to differentiate it from certain phobias, at the roots of which
disagreeable experiences are not seldom revealed.
As syndrome the expectation complex may appear in any other
a
neurosis and also in psychoses; indeed, in schizophrenia it can dominate
the picture for decades in the latter case, to be sure, there is more than
;
one expectation symptom.

Left to improper treatment the suffering usually be-
itself or in
comes aggravated and continues indefinitely. But once the diagnosis

is definitely made, it is possible to bring about a cure in a few weeks
or months through a definitely laid out psychic treatment such as

enhghtenment, calming, and reeducating. Even in schizophrenia a
cure (of the syndrome) is not excluded, although it is rare.
D. The Compulsion Neurosis
The common diagnostic sign of compulsion neurosis, according to

Kraepelin, a vivid feeling of domination or fear indicated by ideas
is
that obstrude themselves. At the same time the incorrectness of the

content is usually recognized.
In the compuhive ideas any kind of idea obtrudes itself; it may be
a musical motive, the idea of a funny face, a ghost's hand, an odor, a
voice, of which one cannot rid himself. It frequently concerns dis-
agreeable something disgusting, immodest processes, blas-
things:
phemous it may be in the form of questions (questioning
utterances, or
mania, reasoning mania). The content of the questions may be indif-
ferent, e.g. how the furniture of a room was arranged, why a table is
.
rectangular, what is the date of newspaper lying in the street; other

questions concern the creation, infinity, (jod, the Virgin Mary; then
also all sorts of sexual problems. Some compulsive ideas force them-
selves into some sort of action, as in the case of the arithmomanias,
the obsession to count everything possible, or to make calculations
with any number that presents itself.
The obsessive fears (phobias) concern some threatening misfortune,

such as the fear of being struck by lightning (Kerauno-phobia) of ,
being robbed, of being attacked by an animal, of meeting with an acci-

dent while riding, of injuring oneself and others with a sharp object
which happens to be near (aichmophobia) of being killed by some ,
object falling from above, of contaminating oneself with dirt, bacteria,

bichloride of mercury and thus make oneself and others sick. Precisely
those thoughts which are especially terrifjang to the patient come up
most often; thus one observes blasphemous ideas in the religious, and
murders in the chicken hearted, etc.
Kraepelin also includes here the somewhat peculiarly appearing
phobias of space, claustro-, nyctophobia, fear of traveling, and fear of
tunnels.
The fear of responsibility expresses itself in the compulsion to
examine repeatedly whether a match thrown away no longer burns,
whether the doors of closets are locked, whether letters are sealed, or
whether no mistake was made in the calculation (doubting mania, jolie
du doute). Other patients are obsessed with the idea that they must
always be particularly careful not to overlook anything; they might
e.g. hear some one calling for help. Others fear lest they should forget
names and are thus constantly compelled to think of them and
repeat them [onomatomania). Others are afraid of their working
tools, or entertain some fear of beginning their work {aboulie
projessionelle)
The fear of guilt usually consists in the fact that the patient
imagines that he might do or has done something wrong or clumsy;
this is not only accomplished deliberately through commission or omis-
sion, but the patients also fear that they might destroy their beloved
ones through a thought ("omnipotence of thought," which shows a
predilection for the compulsion neuroses) . Then there are phobias that
the patient must hang himself on a certain hook or that he must steal.
In the phobias of contact with people [homilophobia) the patient fears
e.g. that people direct their attention to him; here belong the examina-
tion fears, the phobias connected with clothes and the fear of
blushing (ereuthrophobia) ; a teacher had the phobia that the children
would see the slit of his pants.
.

The patient usually reacts very strongly to these phobias ; in part,
by avoiding all opportunities of coming in conflict with the fear, and
by acting in the sense of the phobia. Thus when there is a phobia of
bacteria, they constantly wash their hands, and touch nothing that
anybody else might have touched. In aichmophobia they look
everywhere for needles, they open their letters thirty times in
order to see whether one is not wrongly addressed, they cross the
threshold twenty times forward and backward, and similar acts.
One was compelled to mow the same place
of Kraepelin's patients
73 times in succession. Others have definite defense movements and
magic-like protective formulae, which they must utilize on all such
occasions.
The primary obsessive impulses, in so far as they lead to action, are

more rare; Kraepelin believes that, principally, they are something dif-
ferent, for it is usually a question of fearing that one could do some-
thing. Still there is no doubt that obsessive impulses sometimes occur
with action, even outside of dementia prsecox. Many add here also
the maladie des tics, coprolalia, echokinesis, miryachit, and other
phenomena.
It is the anxiety which in all cases drives the patients to actions
or to omit actions. Frequently the patients can somewhat control the
obsessions, but they are then afraid of the anxiety (phobophobia)
How doubt and impulse are connected is shown by the fol-
closely
lowing example: Already when in college the patient had the impulse
to tell any one of his teachers that he is an ass or to write it on paper;
later he had the impulse to set fire to the curtains and the provisions in
his business, to embrace every feminine person, to stick a pointed
instrument into every bald head, and to put glass into the pans. At'
the same time he had doubts whether he had already performed this
nonsense; he had to pick up all pieces of paper in the street to see
whether he had not written anything against the honor of others; he
was to go to the stores to see whether he had not set fire to them, etc.
He began to study medicine, but the thought obtruded itself that all
patients could be well by the time he will have passed his examina-
tion, and he would then have to starve (he had an income). He
changed to the study of theology and then he feared that he could
perhaps show his tongue from the pulpit. Dozens of such ideas pre-
vented him from becoming something, although 'he finally began to
study law.
As a rule, the patients recognize the incorrectness or the nonsense
of the obsession, and struggle against it, whereas the delusional patient
struggles urith his idea; still despite this insight there is some sort of
.
belief;it is something like the man who "in daylight mocks at ghosts
but not desirous of hearing about them at night." At the height of

is
the affect they may merge for a short period into an indiisputable
delusion.
Besides these obsessive forms, the special enumeration of which
could be immeasurably increased, one also speaks of obsessive affects,
obsessive inhibitions, obsessive feelings, obsessive hallucinations and
similar phenomena. I do not quite know what there is tangible about
it to understand.
The compulsive neurotics are mostly individuals of little energy
who feel timid, and not sure of themselves, but they are diligent and
conscientious people. The mood shows a tendency to depression and
fearfulness. The intelligence is strikingly often above the normal.
The physical symptoms of compulsion neurosis are of all possible
nervous and vasomotor manifestations; there are also hysteroid
disturbances.
The course of compulsion neurosis is a very dragging one. Fluctu-
ations in intensity can occur, the content can change, while the fear
remains the same. Still the picture on the whole is very monotonous.
The beginning of the disease may already be indicated in childhood,
very often at puberty; in the majority of cases it occurs before the age
of 25 years. Sometimes it can be dated from a definitive event, some-
thing like forced washing by sympathetic instructors, or religious
scruples at the first communion. At the period of involution a gradual
improvement usually occurs up to a kind of recovery.
The first cause is the hereditary neurotic disposition which fre-
quently manifests itself in the family in a similar way. As to its
distribution among the sexes, the statements in reference to men
fluctuate from 29 (Janet) to 60% (Kraepelin)
The psychic mechanism and with it the precipitating causes are
still insufficiently known. One was always struck by the connection
with sexuality, and Freud would trace all cases to sexual complexes.
In any case affects from the original initial idea are often here trans-
ferred to other ideas. Frank '^^ has also demonstrated that repressed
affects may assume compulsive significance through new and similar
experiences.
The compulsive syndromes occur in the most varied dispositions and
manic depressive insanity, and de-
diseases, especially in neurasthenia,
mentia praecox, but only when they seem to have originated inde-
pendently on a psychopathic basis docs one call the picture comjndsion
"* Affektststorungen, Studien iiber ihre Atiologie und Therapie. Springer,
Berlin, 1913.
neurosis}''^ Corresponding to its genesis, it is often mixed with all
kinds of other nervous and hysterical symptoms.
Outcome.In true cases of compulsive neurosis a cure is not easily
attained. Patient education, mental gymnastics following Oppenheim,
or Dubois's persuasion are supposed to have some success. I have
seen some complete cures, at least from the practical side, by psycho-
analysis (following Frank). It is a striking fact that "independent"
compulsion neurosis is seen only in people who can permit themselves
that disease, and that the symptoms always go only so far as the cir-
cumstances (and the doctors) permit; moreover, in the war, where it
was disregarded, it is said to have disappeared. Kraepelin justly warns
against tearing away these timid patients, lacking in energy, for an
unnecessary long period from their vocations. They should better be
accustomed to work and activity and trained to be energetic.
E. The Accident Neuroses
The psychic disturbances which originate directly from brain

injuries are organically determined diseases with local and general
symptoms. The latter include especially marked irritability, intoler-
ance to alcohol, and from mild to severe epileptoid moodiness and
mental unclearness; in addition there are more or less localized head-
aches and other parsesthesias. These diseases are naturally not
traumatic neuroses}^^
By the latter name one understands diseases which psychically
originate ^^^ through the excitement of the accident or otherwise as a
result of the same, but they can naturally become connected with direct
traumatic or toxic influence (carbon monoxide, in explosions). From
the outwardly different forms Kraepelin has emphasized four pictures
which designate the most important directions of the causation and
with it also the symptomatology; to be sure, they cannot be sharply
distinguished.
(a) The fright neurosis. This name the author now still uses only
for the pathological reactions to the experience of a profound catas-
" The typical cases have so much about them that is schizophrenic in appear-
ance and heredity, that one cannot suppress the suspicion that they are actual
schizophrenics whose symptomatology exhausts itself in compulsive syndrome.
"" See
p. 240.
^*^Some, especially Oppenheim, assume for at least many cases a more physi-
cal basis, some molecular change of the nervous system through a physical or
psychic "concussion," resulting from an extremely strong stimulus, indeed one
even speaks of traumatic reflex paralysis. Following the war experiences these
things are quite secondary.
trophe (earthquake, mining accident).'**^ Beside.s ntuporous inhibitions

therecome about various grades and kinds of disturbances of conscious-
ness with excitements. Orientation becomes disturbed; in mild casee
one observes distractibility, forgetfulness, and marked fatigue; in
severer cases it may come to dehrious states of an unclear character,
often with quite senseless acts. Sleep is poor as a rule and disturbed by
terrifying dreams. Palpitation and all the other signs of vasomotor
lability, furthermore trembling and dizziness, complete the picture and
usually continue longer than the delirious states. The latter last from
hours to at most a few weeks; but even more chronic symptoms are
wont to disappear regularly in a few months at the latest. For the
period of the strongest excitement there is an amnesia in most cases.
Under certain conditions the most profound is supposedly capable
fright
of producing a direct lethal effect.
The difference from hysteria consists in the fact that the morbid
manifestations represent here only a strongly exaggerated but qualita-
tively normal reaction to a frightful experience, whereas hysteria pro-
duces own symptoms. The hysteric has a reason for being sick
its
and for showing quite definite symptoms, while the fright neurotic has
not; that accounts for the qualitative difference and particularly also
for the indefinite long duration of the hysterical reactions.
Recoveries of fright neurotics come as a result of time and rest, and
calming measures, also raising of self-confidence, and similar means.
Concerning the pseudo-dementia following an accident see p. 545.
(b) Most of the psychiatrical accident cases of peace practice
show the picture of traumatic neurosis ^^^ which Kraepelin characterizes
as "a, depressive or morose moodiness with woefulness, weakness of will,
and all sorts of physical morbid manifestation partly of a general
nervous nature, and partly local." The patients regularly complain of
difficulty in thinking and of poor memory; but by objective examina-
tion the disturbance cannot be demonstrated, although thinking is
retarded, and if the patients are put to mental or physical strains, even
of only a mild degree, unbearable added manifestations rapidly show
themselves, which in part are also otherwise present. The symptoms
are as follows: pains, especially in the head, but also elsewhere, and
palpitation with an objectively rapid pulse. Thus efforts to work are
feared and at least as long as the patients are under observation all
movements are restricted if possible, so that the patients sit around

^
Stierlin. Uber psycho-neuropathische Folgezustiinde bei den Uberlebenden
der Katastrophe von Coiirrieres am 10 Miirz 1906. Diss. Zurich 1909 oder
Monatschrift f. Psych, u. Neur. Bd. XXV.
^
The expression is unfortunately also used for "fright neurosî^" and by
Hamburger also for psychogenic pavor noctumus.
more inactively, they walk only slowly, not only avoiding exertions
but also firm attitudes and all excitement. Besides the army of vaso-
motor disturbances, including dermographia and dizziness, the severer
cases are regularly tortured also by an objectively demonstrable
insomnia.
Tests in continuous arithmetic, especially those done in Kraepelin's
laboratory, show that a true increase of fatigue (in contradistinction
to organic brain disturbances) does not exist, but that a greater part
of the behavior is explainable through a lessened effort of the will. The
same shows motor activities.
itself also in registering
For the further multiform symptomatology we must refer to the
textbooks on accident diseases.
The traumatic neurosis is wont in most cases to drag on for quite
a long time, or it may even be incurable, unless a satisfactory settle-
ment, possibly in one sum, puts an end to the misery.
(c) The Damage Suit
Litigants. In some individuals who suffered
through accident, the struggle for an income becomes active.
injuries
Not only do they imagine themselves wretched, but they also con-
sider themselves unjustly treated and defend themselves against it,
as well as by exaggerations and falsifications, as by non-recognition of
the court's decisions and by incessant appeals, in which finally libels
and threats are not lacking.
The 'damage suit litigant is probably incurable as long as an award
in his favor is to be obtained, and when the litigation has continued
a long time the prospects are probably rarely bettered through settle-
ment in the paranoid character of these patients. The more important
therefore is the prophylaxis.
(d) Traumatic hysteria can be described together with the ordi-
nary hysteria some peculiarities which correspond with the origin are
;
not important in principle.

Conception of the Accident Neurosis. With the exception of the
fright neurosis these diseases mainly originate from the "struggle for
damages." The fear of the front (in war) has (consciously or uncon-
sciously) a similar significance. In the accident neurosis in peace time
the anxious idea to be sick and incapable of earning a living is in the
foreground, which could in a measure be compensated by an award (or
settlement sum) "If I should become well the compensation would
:
be gone; the disease may also return, for it is so bad." Hence the
constant care of oneself and the avoidance of every effort to regain
the capacity for work. Through anxious expectation certain groups
of paresthesias can then be produced with relative ease ; among those
are especially headaches^ cardiac symptoms, and sleeplessness, The
anxious avoidance of all exertion of will leads to a lack of energy

and hindrances in thinking, so that the relatively uniform structure
of the morbid picture in the principal components can be easily under-
stood. In the damage suit litigants the desirous ideas are in the fore-
ground; such people were happy to have met with "their accident"
and now the deserved fortune is kept from them. This explains the
reaction.
The enormous mass experiment of the war has furnished corrobora-
tion of this conception in themost striking manner for those who .still
had any need for it. It was known, even before, that without a "mor-
bid gain" even a trauma produced no neurosis; that even injuries like
a fracture conditioned a longer working incapacity in pension receiv-
ers than in others, but where no pensions rewarded the lasting disease
(in the case of different laws, in the non-insured, in elemental catas-
trophies, in duel and sport injuires), there was never anything of a
traumatic neurosis to be seen, and that where a monetar^^ settlement
was customary, the disease continued only until the money was
received. In the war, therefore, where there was not only the prospect
of a pension, but also of freedom from the horrors of the front, an
enormous amount of material was observed, in whom the severer
injuries produced no neurosis, although that alone was sufficient to
incapacitate from service and furnish a pension, and that prisoners of
war, with few exceptions that could easily be explained, remained free
from neuroses. Significant are also the cures (and eventual relapses)
through suggestive influences.^^*
To be sure, there are still other motives for a traumatic neurosis be-
sides pensionand fear of the front, but for some reasons they recede into
the background in the present laws. All those morbid gains which pro-
duce the neurosis may sometimes also become active here; the injured
may have a special interest in showing what a misfortune was produced
by him who was the cause of the injury, etc.
In the damage suit hysteria we must have in mind still other deter-
mining cases besides the desirous ideas, be it a permanent disposi-
tion to hysterical expressions, be it in the factor at the basis of the kind
of trauma, as, for example, fear producing a tendency to tremors.
But all three forms must be afraid to work because their income will
be thereby diminished. This is so constant that a traumatic neurotic
who makes an earnest effort to resume work and accomplish as much
as circumstances permit must always arouse the suspicion that it is a
question of an organic disturbance, or at least of a complication of
the neuroses with some other malady, especially a brain injur^^
^^Comp. Naegeli, Unfalls- und Begehrungsneiirosen. Stuttgart Enke 1917.
The statistics concerning the frequency of the accident neuroses give
very different numbers. They may appear in perhaps from 1 to
2% of all damage suit accidents. With the kind of injury they
have little connection, although traumas which affect the head will for
conceivable reason preferably settle there. An essential cause lies in
the disposition, which causes certain people to give up their own exer-
tion, in order to live as parasites; frequently it is the environment,
which systematically nurtures the desirous ideas, especially the wife.^^^
Unfortunately the chief cause of the disease is frequently the un-
skilfulness of the doctor, especially at the beginning of the treatment.
If instead of supporting with all means the positive suggestion, the
doctor pities these people, making the patients and himself important;
if he considers the consequences as serious and prognosticates a long
duration; if he "treats" too much, voluntarily advising against work,
and indicates that serious consequences may first follow later, etc.,
then it is not to be wondered at when there is an outbreak of the
"iatrogenous" neurosis or psychosis. Warning must be sounded
against the not nearly limited advice, "to be careful of oneself," which
sometimes defers the cure for a long time also in other diseases. If care
is needed, it should be given in as accurate doses as any other remedy.

A worse produced by the insurance societies and their
effect is
investigators, who do not
desist from worrying and irritating the
insured patients; they exact foolish conditions, like the one that the
patient must not work as long as he draws compensations. On the
contrary, it is good if these people can through work add a little to
their incomes and even earn a little more than in healthy days. Fre-
quently the injured are first driven into the disease by unnecessary
litigations for the rightful compensation. A possibly rapid, definite,
and somewhat noble settlement will usually prevent the neurosis; the
same may be accomplished by the opposite way, namely, the indis-
putable non-recognition of the right to compensation. Psychologically
these two latter methods are naturally identical, for they both destroy
the desirous concepts of the neurosis.
Although the pathology of traumatic neurosis is clear, it is not at
all simple in individual cases to make the diagnosis, to decide upon the
expert testimony, and the therapy. The insurance laws, the influence
of good and bad advisors, as well as some other things, very strongly
complicate the state of affairs. It is the duty of every physician to
orient himself through special textbooks and courses concerning all
these relations.
In cases where after definite regulation of the claims the will to
"" Comp. the characteristic fairy tale of the fisherman and his wife.

work does not spontaneously remove the still existing hindrances, it

requires skilful management to lead the patient back to work. It may
e.g. be well to advise the patient to take up first some new occupation
as something lighter. If after this long idleness he is then unable to

accomplish as much as those who are practiced in this work, and if
he still tires rapidly, it is quite clear even to himself, and leaves no
depressing effect, and the demand for the work, which he understands
best, then comes without any further interference.
Xm. THE PSYCHOPATHIES

The psychic deviations from the normal which do not give the
impression of pronounced insanities, which are based as a rule on
heredity, but occasionally also on a former mild brain disease, are
designated by various names, but are always vaguely differentiated.
They are spoken of as degenerates,^^'' constitutional cases, original
anomalies, psychopathies, abnormal characters, etc. The affective
peculiarities are in the foreground in most cases. Even if there is an
average or great intelligence, it has little regulating influence on the
actions.
We have here to deal with deviations from the normal in all possible
directions and mixtures. Hence psychopathy is only in so far a uniform
concept as it embraces psychic deviations from the normal that are not
limited in any other way; but it is always incorrect to say that "the
psychopaths" have this or that quality. According to the nature of the
thing, they cannot have any definite limitations and no symptoms that
are common to ali. Every individual is really again something special.
Nevertheless certain principal features and correlations frequently
repeat themselves, so that for the purpose of the discussion some types
can be particularly emphasized without doing too great violence to
reality. But one must be quite clear that it involves only artificially
differentiated pictures, and that next to these pictures and between
them there exists in reality an infinite shading of variations, transitions,
and combinations.
From what degree of the intensity and the grouping of the symp-
toms one wishes to designate the psychopath as sick is arbitrary, and
from what degree one no longer wishes to consider him as a psycho-
path, but as insane, is not seldom the same. Many psychopaths are
really only in the social sense "not insane"; before the forum of
"We avoid the name and concept of "degeneration"; comp. p. 201. A part
of what is so called was recently brought into connection by Xacgeli with the
more fruitful concept of mutation.
natural science they suffer from the same anomalies as many insane,
only in slighter degree they are paranoid, schizoid, latent epileptics,
;
cyclothymic, etc.
A great many of them do not
really come to the doctor on account
of their constitution, but on account of the false reactions conditioned
by it, which frequently assume the form of ordinary neurotic symptoms,
but still more frequently any other kind of irregularities which have
not yet been emphasized. Some are really inseparably mixed morbid
pictures of congenital and reactive anomalies. This is true of most of
the sexual aberrations, which are false attitudes on an abnormal dis-
position, wherein now the one, now the other factor predominates.
Of the endless varieties we can here give an indication of only few
types, in which limitation I adhere to Kraepelin, without, however,
adopting strictly his classification of original morbid states and psycho-
pathic personalities.
Kraepelin conceives the psychopathies as circumscribed inhibitions
of development, which he puts in contrast with the general inhibitions
(oligophrenias). Although such disturbances certainly exist, and the
development in later age blurs some of these symptoms of the disease,
the theory is probably premature and in any case does not embrace
the entire group. In all domesticated creatures there are many, and all
sided deviations from the normal, and certainly also in human beings;
it is therefore probable that the majority of the psychopaths belong
to this class of deviation. Besides, much too much may be explained

through infantilism, and above all, the concept of the evolutional
inhibition is still quite unclear as soon as one wishes to apply it to
the facts, and in relations simpler than those of psychiatry it is really
only rarely of use. These are only a few indications of objections to
this theory.
The treatment of the psychopathies is not a very grateful task, for
one cannot naturally change them one must try to get along with them.
;
At all up to a certain degree

events, excitable patients can be educated
of controland especially to a prophylactic avoidance of situations that
are dangerous for them, and under favorable conditions fairly tolerable
situations may be attainable for some. Rules can hardly be given,
for the individual as such and the peculiarities of the environments
must determine the behavior. It is quite obvious that unnecessary ex-
citement should be kept away from such must abso-
people, but they
lutely know and feel that there is a limit to the tolerance of their
excesses when carried to a certain degree, and that a transgression will
automatically bring its counter measures whereby neither excuses nor
subterfuges, in fact, no discussions whatever, will be permitted. It is
THE INDIVIDUAL MENTAL DISEASES o71
usually best to ignore the smaller things, even if in cases where an
actual education is not impossible sometimes very useful to start

it is
from little things; in any case, a neglect of consequences will always

have to be reckoned with. As everywhere else it is particularly im-
portant to create an interest, an aim, for which the patients could
strive, whereby definite traits of character, even if no virtues in them-
selves, such as vanity and pride, should often be made use of unre-
servedly, but should be developed within proper bounds. If the patient
shows a hopeless apathy towards useful occupation, he can perhaps

be interested in sport, art, in some scientific hobby, or in something
similar; at the same time real work must never be neglected. In
most cases it is impossible to educate the patients in the milieu in
which they grew up; they must be taken elsewhere. But we have
not as yet enough people who have the will and the necessary skill to
assume this task, be it in a sanatorium together with others, which
is not dangerous only if "the others" are not also moral defects, or in
a private family. The closed institution can in some regards accom-

plish much more than the open one; it is used much too little. Some
of the moral idiots are treated by the penal code, but this is neither
to the advantage of the patient nor to society. But our views and
laws and arrangements do not as yet permit any proper treatment
of so many cases who could otherwise be well managed.
However, in many cases one should follow the important rule, to
do that which is necessary, or promises some results, and not that
which might induce feelings of revenge, coddling, or useless sympathy.
A. Nervosity
Under nervosity Kraepelin understands a "permanent injury- to
life's work as a result of an inadequate predisposition in the spheres
of activity of the emotions and will. It is, on the one hand, mainly a
question of a defect in the ability to resist emotional influences, and.
on the other hand, of an insufficient power of will. This is regularly
associated with a lack of equanimity in the development of the entire
psychic personality." The development of intellect is frequently good,
or very good.
The chief disturbance is in the sphere of affectivity; the patients
react stronger to inner as well as to outer influences. "Everything gets
on their nerves"; they are easily worried, or also easily pleased. It is
especially on this account that the unfreedom of the will originates.
"They lack the trustworthy guide through a firmly formed channel."
In addition, one observes a progressive fatigue which does not at
all seem to show itself in all positions. Some inspiration or any other
favorable affective state can often keep away the fatigue for a long
time, so that in some cases must be questioned whether the heightened
it
fatigue is not to be regarded as an emotional effect rather than a

constitutional anomaly.
Thus the capacity to work is irregular and on the whole consider-
ably diminished; nevertheless the patients are usually inclined to
overestimate themselves.
The memory is often unreliable and uneven. The phantasy readily
gets the best of the ideas relating to reality. Sexuality plays a par-
ticularly big role.
These conditions naturally show no barriers to either healthfulness
or neuroses. Moreover the prodromata of quite different mental dis-
eases, especially paresis and schizophrenia, resemble these nervous
manifestations, often to the extent of being mistaken for them. In all
cases one must therefore also think of these psychoses and exclude them
through the anamnesis and the absence of their specific symptoms.
Besides these general persistent manifestations there are also many
quite morbid features, idiosyncrasies, nervous dyspepsia, insomnia,
hysterical signs, and similar symptoms.
Course:In most cases the disease usually shows itself already in
childhood, frequently reaching its height in youth, but in many cases
it shows later a gradual decline.
In his classification Kraepelin finds 65% men, probably because
such anomalies disturb a woman less in her usual callings, and con-
sequently the physician sees less of her, or because she is designated
as hysterical.
Naturally the treatment is essentially a psychic training; at the
same time the external conditions should be regulated as much as pos-
sible. Among medications bromide should be mentioned, which, in a
great many attacks of moodiness and (apparently) exhaustions and
irritating weaknesses, frequently gives quite good results after a few
doses as well as after prolonged use.
B. The Aberrations of the Sexual Impulse ^^^

Among the sexual aberrations onanism is so common that it is a
controversy to what extent it is really abnormal. At all events it is
considered morbid if it appears in early childhood (under certain con-
,^^^ already during the first year), or
ditions it comes spontaneously
^^ Krafft-Ebing, Psychopathia Sexualis. Stuttgart, Enke, 14 Ed. 1912. English
Translation of the Tenth German Edition, Samuel Login, N. Y., 1908.
^^ Not so rarely servant girls criminally stimulate the genitals of the little
ones entrusted to them, in order to calm them or to gratify their own sex plea8~
ures and thus habituate even normal children to onanism.
when it is practiced excessively, and when it is used as a substitute for

the normal sexual relation not only on account of moral but also for
other reasons ("onanism of necessity"). Moreover it accompanies
regularly also the actual sexual abnormalities. It is not only per-
formed through the excitation of the sexual parts but under conditions
through a mere activity of the phantasy which leads to the orgasm
("psychic onanism").
Naturally onanism easily becomes harmful, because it gives every
opportunity to excesses, because it deflects from the normal sexual
aim, and above all because the feeling of guilt and the constant un-
successful struggle against the "vice" consumes the psychic power,
diminishes self-confidence, and gives cause for hypochondriacal and
neurotic symptoms often of the severest kind.^*^
In the treatment of onanism, severe punishments, long sermons, and
mechanical restraints are mostly harmful, and perhaps never useful,
whereas diversion through play and work, arousing of other interests,
and a healthy conviction of natural attachments have often made one
forget the bad habit relatively easily. If transient states of sexual
excitation are at the basis of the onanism,e.g. in schizophrenia, one can
sometimes ease the patient's struggle with daily small doses of bromide.
From onanism must be separated the state of being sexually in
love with one's own figure and person, the narcism, which Freud con-
siders as a normal passing stage of sexual development, and which is
supposed to be found at the root of some psychoses and neuroses.
The normal attraction of the other sex can degenerate into a morbid
impulse of exhibitionism, in which even where there is an opportunity
for normal sexual relation, the patients find their true gratification only
in exhibiting their genitals (eventually parts of the body otherwise
covered) with or without simultaneous onanism. In imbeciles, the
exhibitionism not rarely furnishes a substitute for the inacessible coitus.
For reasons that are not quite obvious it frequently occurs in organic
mental diseases, sometimes in epilepsy in the twilight states.
Fetichism is a pathological exaggeration of the normal transference
of erotic feelings to parts of the body and objects of the beloved person
(hair, "braid-cutters," pieces of clothing, especially shoes). The ob-
jects in question are not always acquired in a legal manner but are
often needlessly stolen simply because the theft seemingly contributes
to the sexual gratification. They are said to stimulate sometimes by
looking at them, but in most cases they are brought into contact with
the genitals and used for onanism. Normal coitus is usually not
desired some, however, use the fetich to make themselves potent.
;
" Comp. p. 209.

Voyeurs find their gratification in watching coitus in others, the
Renifleurs by inhaling the odor of urine and the Coprolagnists through
intimate contact or even through swallowing of excrements.
Another form of displacement in the object is pedophilia, or the
which occurs
desire for relations with children of the opposite sex,
perhaps most frequently as an acquired anomaly in senile dementia.
(It is not rare also among imbeciles faute de mieux).
As pederasty one designates at present only the gratification of
a manwith male individuals through coitus in ano. It is less common
than the talking about it would lead one to believe.
Sadism ^^ is an exaggeration of the erotic pleasure in dominating
and torturing which is especially so frequently displayed also by the
male in animals. Masochism ^^^ is the caricature of (feminine) yielding
and a certain erotic pleasure in suffering pain. The peculiarity becomes
pathologic through the fact that it becomes exaggerated and is then no
longer a concomitant phenomenon of the erotic act, but an independent
aim. Individuals so afflicted find the only or at least the necessary
means to gratification in causing, or in suffering, pain. The two abnormi-
ties areseldom found isolated; usually they are associated in the same
individual even though as a rule one strongly predominates. Sadism
and masochism are also designated as active and passive algolagnia.
The name sodomy like that of onanism has displaced its meaning. It
now designates exclusively the relation with animals which is not really
due to morbid alteration of the impulse but is regularly practiced faute
de mieux, especially by half mature people, lonely shepherds, imbeciles,
and also by some feminine persons who live intimately with their dog.
Transvestites feel well only in clothes of the other sex, without
being homosexual.
In rare cases the sexual aberrations, as well as the force of the
impulse, show a periodic character in so far as they appear from time
to time, but usually only for a few days and then again make room for
the normal (or sexually weak) behavior. More frequently they appear
only under the effect of alcohol.
The various kinds of parasexuality are usually connected with a
premature appearance of the sex impulse and hence can become known
very early, frequently at the age of three or four. Most of them are
incurable in part simply because such patients, following their feelings,
actually consider their form of sexual impulse as the only pleasant
one and therefore dread a "cure," as much as a normal person dreads
castration.
^ Named after the Marquis de Sade, a writer afflicted with this disease.
'"^
Named alter Sacher-Masoch who portrays this anomaly in his novels.
The theory of sexual aberrations despite its extensive literature is
still quite obscure. The majority of its bearers are also otherwise
psychopathic, but in the most varied directions. The moral qualities
have no direct connection with the sexual abnormalities; nevertheless
the psychiatrist naturally recognizes a selection in which the moral
defects dominate.^^^
The diagnosis is usually easy. But one must not imagine that
every sexually abnormal person himself knows his condition; one mu.st
bear in mind that all sorts of mixed and transitional cases may occur
and furthermore that the limitation of the normal sexual activity must
be stretched pretty far; in this sphere one must not be surprised at
anything and consider nothing impossible.
Treatment. In milder cases something can still be accomplished
through proper training, eventually through hypnotism: But even
when the possibility of cures may not be excluded, they cannot be
attained in most cases, because the technique is a ven,^ rocky one. If
such a patient is not married, how shall one gradually initiate him
into normal sexual intercourse, without exposing him to new, moral
and other dangers? Where something is to be attained through self-
control, one does well under all conditions to train the patient to
abstain from alcohol, not only on account of the effect on the inhibition
of the impulse, but also because alcohol sometimes first permits the
perversion to come to the surface.
Special consideration must be given to homosexiuility , or contrary
sexual impulse, or uranism,^^^ the sexual love for persons of the same
sex.^* It is gratified in various ways, sometimes through mere com-
panionship or looking at the person, but much more frequently also
through all kinds of excitations of the genitals; in contrast to this
there is a feeling of indifference or disgust towards contact with the
opposite sex. With such people all sexual desires, actions, as well as
the day and night phantasies are directed to the same sex. As a
matter of fact homosexual love shows the same signs as heterosex-ual
love but shows, particularly frequently something strikingly ecstatic
and exalted, and only very exceptionally is it lastingly monogamous,
although it isby no means free from manifestations of jealousy.
^" See below Homosexuality.

^^ From Venus urania following this terminology Ulrich calls the male
;
homosexual "urning," and the female "urninda." The corresponding name for
heterosexuals, which is, however, little used, is "Dioning" from Diona, the mother
of Venus Pandemos.
"^ Hirschfeld, Homosexualitat des Mannes und Weibes, Berlin, Marcus, 1914.
Cf. also Chap. XI, in Brill's Psychoanalysis, Its Theories and Application, 3d
Edit., W. B. Saunders, Philadelpliia.
Noticeably frequent the orgasm takes place without friction. Abnor-
mal practices such as cuni-peni anilinctio and other kinds naturally
play a greater part here than in heterosexual gratification; pederasty
(immissio penis in anum) is more frequently rejected with disgust
than desired. A mingling with the various other abnormities such
as fetichism, sadism, masochism, eta., is not rare. The feeling of
shame manifests itself particularly toward the same sex and often in
a very exaggerated manner, an indication how little it is to be sepa-
rated from the positive impulse. The common existence of an ex-
aggerated sexual demand is only a partial manifestation of the very
changeable affectivity, which readily fluctuates between the highest
pleasure and deepest pain on the other hand the aggravation to anger
;
and worry recedes comparatively in contrast to the positive and nega-

tive esthetic feeling, which causes delight at the sight of a loop colored
in accordance with one's wishes, or makes it ''unbearable" to be in a
room, which is not furnished according to one's taste.
The tertiary psychic and physical sex characteristics of the same
sex are often slightly developed or even substituted by those of the
other sex.^^^ The following are to be noted: An inclination towards
the feminine in all possible spheres, in work, decoration (preference for
feminine attire) , in taste, in thinking, in mimicry, and in gait in the ;
entire behavior of a large number of urnings it is something common
to see a slight indication of the feminine up to a complete imitation

of the woman ; the reverse can be seen in the urninda. The man with
a slightly developed beard, high pitched voice or broad pelvis and the
virago are relatively more common among homosexuals than among
those of normal sexuality ; nevertheless these anomalies of the physical
partial manifestations markedly recede in frequency when contrasted
with the psychic manifestations. According to Fleischmann the latter
are found in 24% of his male homosexuals, where he includes appar-
ently very slight deviations from the average. Only in exceptional
cases are the genitals abnormally formed.
All homosexual peculiarities show themselves very frequently from
the earliest age. The boy likes girls' games, and hangs on his mother's
apron strings, and the girl runs around with boys. Early sexual de-
velopment is quite usual, in which the abnormal direction can as a
rule be seen from the beginning.
The ethical feelings are just as differently developed as in those who
are sexually normal; still, at least in asylum practice one finds com-
paratively many morally defective urnings next to those of high stand-
^ "Androgynous" = men with feminine build of body and "Gynandrous" =
women with masculine build of body.
ing. That they are on an average especially prone to lying is cer-

tainly largely the result of the false position into which they are forced
by the general customs and views of human society, which are formed
on heterosexual patterns.
Also in the intellectual spheres one observes in these people all
nuances; abnormities in all directions are as common as among other
psychopaths.
Most homosexuals are neurotic in some manner. Excluding the
secondary sex characteristics of the other sex, one does not find
physical "stigmata of degeneration" more frequently than in normal
people.
Formerly there were disputes as to whether homosexuality is a
vice; there isno need of discussing this. Whether it is a disease,
belongs to the sphere of foolish questions, especially as long as the
concept of disease cannot be limited and it is not known what conse-
quences one should deduct from it.
More important the investigation, whether it concerns a con-

is
genital or an acquired, and hence avoidable disturbance.

In favor of an acquired disease aside from many empty reasons
about which one reads ^^'^ are: some other sexual anomalies, especially
fetichism, can hardly be explained differently than through an acci-
dental association of one of the first sexual excitements with an unusual
object. It is quite natural to assume a similar origin for homo-
sexuality, for at present it is hard to imagine how nature happened
to produce so frequently such an anomaly, which seems to contradict
the manifoldly confirmed view that the germ glands determine the

other sex characteristics. It is moreover noted that mutual sexual
activity takes place in prisons and in all other places where persons
of the same sex live alone in close contact more or less deprived of
the other sex. There are also schools where homosexuality is con-
sidered something more superior than the proletariat service of Venus
vulvigata and thus seem to have a certain recruiting force. Psycho-
analysts wish to trace the anomaly among other things to a strong
attachment for the mother, and as a matter of fact one can sometimes
find indications that such patients find it particularly hard to detach
themselves from the mother.
All these reasons are in no way valid; none of the modes of origin
ever brought forth can hardly even be assumed in a great number of
patients, except the attachment to the mother which has not yet been
followed up in a sufficiently large material. If it should really be
"' Here also belongs the hearsay concept concerning the acquisition of peder-
astic "habits" as a result of sexual oversatiation.


found regularly, it would still not yet prove that it is the cause, for it
must also be confirmed somehow, and what is more, according to our
present knowledge, in something that we cannot designate as a con-
genital "disposition." And even if it were certain that fetichism owes
its origin to merely accidental occurrences, it still cannot be imaginable
without a previously existing foundation, and precisely in homosex-

uality an analogous explanation will not quite fit, if only because a
great number of those who are later sexually normal must have ex-
perienced their first sexual stimulations in connection with their own
sex (boarding schools!).
If the reasons for the acquisition of the anomaly are quite insuffi-
cient, there are,on the contrary, very many weighty indications show-
ing that the essential root of homosexuality lies in the congenital con-
stitution, and what is more not only in the sense that the direction of
the sexuality was not firmly established and that an accidental experi-
ence determined the false tendency, but in the sense that the homo-
sexual foundation itself forms the constitutional factor. Here we have
in the first place the fact that many more urnings carry along signs of
the other sex in the physical sphere than would be justified by the
assumption of an accidental determinant of sex directions. Moreover
on closer inspection the direction of the sexuality can frequently be
recognized already during the first or the second year of life, and at
all events in the majority of the urnings it is already determined at a
time when the sexual feelings in the narrow sense play no big part
according to most patients no part at all. Most urnings are finished
products at the third or fourth year at the latest. Moreover one can
hardly understand how through the mere feeling to be an urning an
inclination should arise to assume in all other relations the customs
of the other sex. The urnings have to do with men, and, following
what one otherwise sees under pathological conditions, would therefore
much rather identify themselves with men and avoid everything
feminine, if a primary disposition to feminine behavior would not
hinder them in this.
It is also characteristic that homosexuals are sometimes entirely

ignorant of their abnormity until they pass pubescence when they
become aware of it by accident, while in the acquired sexual aberration
as a result of an outer experience the precipitating cause usually re-
mains conscious, and above all nothing can be noticed during the many
years of this latency period between cause and effect. How firmly
nature determines the direction is shown by considerable experience.
Thus most of the homosexuals grow up in an environment which sug-
gests a direction of the impulse contrary to their own and are still not
changed by it; v/hcrcas heterosexuals, who because of a lack of rela-

tionship witli women occupy tliemselves witii the same sex for many
years, are happy to be able to return to one follows up women. If
the families of homosexuals one will, to be sure, find only in about
8% the same heredity, but exceptionally frequently one will observe
a special lack of fixation of the sexuality, which in different mem-
bers takes different abnormal directions, but persists in the indi-
vidual and very frequently is That some physical
particularly strong.
abnormity is at play is also proven by the descendants of homo-
sexuality, which according to Hirschfe'd is for the greater part deeply
degenerated in various directions. should also not be overlooked

It
that according to all we know about the frequency of homosexuality
it is not directed by outer circumstances, but is about the same every-
where; according to Hirschfeld it fluctuates around 2% of adults.
Of course it also occurs among animals but not much can .be in-
ferred from this as long as no numerical points of support for the
frequency are found. Against this there is another biologic reason,
namely, the continual succession from the pure heterosexual to the
bisexual and from this to the pure homosexuality through all possible
intermediate stages, not only in regard to the direction of the impulse
but also in regard to the physical and mental qualities in general,
in so far as they are connected with sex. I would not know how the
accidental connection of the sexual impulse could produce such equal
shading.
That the theory is still in sixes and sevens can be gleaned from
the discussion itself, and if like many others and especially those who
had most experience, I feel inclined to seek the essential factor of
homosexuality in the congenital direction of the impulse, it is on the
other hand again very clear that in cases of a fluctuating sexual direc-
tion accident may have a deciding influence. And such a fluctuation
exists ; indeed a thorough study of the impulse man shows imme- life of
diately that even the most genuine "Dioning" has his homosexual
com-ponents, and no schizophrenic have I yet studied more accurately
without striking against it. (But I cannot agree with Freud and
Ferenczi, who maintain that these homosexual components are an essen-
tial part of the disposition to schizophrenia, the heredities of homo-
sexuality and schizophrenia are not related.) For the present there-
fore the only hypothesis that can be formulated with any probabihty
is that uranism is a biological manifestation. If it is proven that
2% of the people are e^'e^y where burdened by it, than it may
perhaps be caused by an hereditary mechanism similar to the one that
to 100 women 106 men are born. This could also be reconciled with
the remarkable circumstance that homosexuality does not die out
despite the fact that it hinders procreation to a high degree. The
newest investigations concerning the changes of the physical and
psychic sex characteristics by implantation of germinal glands of the
other sex in castrated individuals may perhaps throw some light on
the subject.^^^ It can be imagined, for example, that in the bisexual
disposition the germ glands too are hindered by the sex determining
causes from choosing between 'two extremes but that there is a sup-
pression of one factor by another, which is never complete and under
circumstances can still change in accordance with the determination
of the development of the individual's germinal glands. At all events
the sex hormones also exert an influence on the psychic direction of
the sexual impulse.
If uranism is a biological manifestation, it is different in principle
from the so-called degenerations, which represent a more accidental
fluctuation about the normal point. The other psychic anomalies
frequently associated with it which we do not differentiate from the
usual psychopathic symptoms, form no hindrance to the theory. How-
ever, if the theory of the biological nature of the anomaly which is
almost only supported by the numerical constancy of the occurrence
should not be confirmed, this naturally would not furnish any
reason for changing the view concerning the congenital nature of
homosexuality.
The diagnosis is self-evident in most cases. One must be careful,
however, not to mistake for homosexuality an occasional inclination
to homosexual acts, and not to classify the bisexual intermediary stages
with one or the other extreme.
Treatment in the sense of attempting a cure is possible only in
the milder cases, that is, in bisexuals ("pseudo-homosexuals"), who

can be educated by hypnotism or psychoanalysis to the extent of re-
sorting to normal activity and even live in happy marriage.
The pronounced cases had to be considered incurable up to the
present. Recently, however, Steinach cured a case by castration and
implantation of another human testicle. Naturally the method is still
to be confirmed. Meanwhile the patients must be taught to resign
themselves to their fate. To know their position and not feel obliged
to struggle against it internally is in itself a relief for many. The
physician can do even still more in regard to calming the patient. In
the first place he can do something for the nervous symptoms which
are provoked by the difiiculty of the situation in general, and espe-
^" See Steinach und Lichtenstern, Umstimmung der Homosexualitat durch
Austausch der Pubertatsdriisen. Miinchen Mediz. Wochenschrift 1918, 145.

cially by the struggle with sexuality, the fear of prison, the worry
about one's honor and that of the family, etc. Persons of delicate
feeling who are especially endowed ethically and religiously reproach
themselves severely, which can be reduced to a bearable measure by
enlightenment. Besides this, stress must be laid on the psychic treat-
ment of the nervousness in general. Some nervous symptoms seem
to come directly from the enforced sexual abstinence (which I do not
recognize as a cause of disease in healthy persons). Here too it is in
the first place a question of the attitude taken. He who is inclined
to assume chastity as something obvious suffers little or not at all. He
who strikes his head against the wall, who consumes himself in the
internal struggle, who looks for excuses in himself not to remain chaste
will naturally be made neurotic by it. In the sense of this reflection

the doctor must educate his patient if he permits himself to be
educated.
As by any occupation that would fill one's
to the value of diversion
life, or by it is the same as in other neuroses.
sport, philosophy or art,
To be sure, it is more difficult to educate a homosexual to abstinence
than the average dioning. For their sexuality is in most cases abnor-
mally excited and their nervous system reacts more strongly. I know
homosexuals who had themselves castrated and are now happy to be
released from the struggle and fear of the prison. Many cannot con-
ceive, however, how one can give up a pleasure of life which the rest
of humanity conceives as the highest. In many cases entering a homo-
sexual "relation" signifies in the first place a release from the struggle
and the neurosis. But the difficulties hardly ever remain away even
if they came only as a result of a desire for change and all sorts of
faithlessness. It is also not always easy to slip through the meshes
of the law, although according to Hirschfeld only one out of 10.000
falls into the hands of the public prosecutor; more, however, get into
the clutches of blackmailers. To be sure, some find their satisfaction
in relationship with a friend withoutcommitting anything punishable.
Emigration to other countries where the urning activity is not punished
is only rarely to be recommended.^^
The punishment meted out to homosexuals in the United States,

Germany, in Austria, and in most of the cantons of Switzerland is to
be designated as unjust from a physician's point of view.^^^ It is also
inconsistent,unworthy, and what I reproach it most with is the fact
that it no use, but hurts also those who are sexually normal
is of
through the prying into sexual relations, and breeds the immeasurably
"* Concerning the for and against see Hii-schfeld.
""The same may be said of England and the United States. Editor's note.
greater evil, namely, blackmailing. The law should only proceed
against seduction, the significance of which, in my experience, is
highly exaggerated, for in most of the seduced that I have seen there
was nothing to spoil.
Naturally the urning is not irresponsible as such, notwithstanding
the fact that the normal person frequently defends himself by pleading
irresistibility of the sexual impulse. Nevertheless, here where the
impulse not only abnormal in its direction, but in most cases also in
is
quantity, and where a mass of other psychic anomalies cooperate, the

limit of responsibility is often permanently or temporarily passed, and
mitigating circumstances are therefore always in order in the presence

of a misunderstanding law-giver who began with wrong premises.
C. Abnormal Irritability
The irritable types react to influences from without in a very

acute and exaggerated manner, which takes the form of attacks of rage
lasting mostly a few hours, despair with suicide, anxiety attacks, or
also stuporous states. During the attack reflection is altogether in-
adequate. Some cases are practically in a twilight state ; the memory
is later markedly clouded; jealousy and alcohol are especially frequent
causes for the precipitation of the morbid exaltation.
D. Instability
The unstable types are distinguished by a lack of persistency of

the affective functions accompanied by an exaggerated resoluteness
of will as a result of inner and outer momentary influences they repre- ;
sent persons who are readily changeable by their milieu. Many of

them become frivolous criminals. They range from the actively
temperaments.
irritable to the apathetic
A 24 year old merchant.His father was a good man, but too
bombastic, and wasted the family fortune. The mother was irritable,
moody, and weak-willed. Her father was fickle-minded and also
squandered his fortune; he was a bigamist. The patient himself re-
ceived an irregular sort of schooling, but was a good scholar; after
his father's death he had to be apprenticed in a business house where
he purloined a considerable amount of money from the stamp bank.
He then got into a reform school, where he did well and because he
had a good voice he was also allowed to take singing lessons. Already
at puberty he left here and there unpaid bills. A little later he spent
more than a year with an aunt whom he could pump in a remarkable
manner, so that she had to withdraw into an attic and start again to
earn her living by handwork, while he kept for himself a bedroom
and parlor and lived very high in general. He was in some business
houses and apparently had a number of engagements as an opera
singer, but could not remain anywhere, partly, but not always, because
he contracted debts with which the police were concerned. One com-
plaint was dropped because he acted more like an irresponsible fellow
than a fraud; in some others where he seemed to have obtained money
fraudulently it did not even come to court. By presenting to the
authorities a forged contract he even deceived the orphanage (at the
age of 23 years). Finally he became engaged to a girl also of a
somewhat from whom he received big sums, partly
light character,
under false pretences, partly by other means, in the expenditure of
which she sometimes participated. She finally had to bring charges
against him. Thus the patient came to be examinedt We found a
very good intelligence, but a slight moral defect which prevented
him from feeling sorry for his bad deeds. Nevertheless his past life
showed that he made repeatedly good resolutions and worked well
for short periods in new places, until he was again overcome by
temptation, which was usually the case after a few weeks or months.
Outwardly he had an elegant appearance and usually felt sure of
himself. But his affectivity showed at the examination an over-
hastiness and a marked inability to bridle his will to the demands
of the task and hold it at the necessary height until the task was
solved. Just as in life, it also showed itself in very simple tests
in which he never could concentrate his attention long enough, and
never could follow resolutions to the end. In his wTitten work he
sometimes began quite well but then lost the thread, or he became
unnecessarily brief and stopped without having finished. About his
financial matter he was not himself sufficiently informed. Whether
he signed a note for 600 or 700 francs he did not notice. Neither he
nor his bride could tell with any accuracy how much he got away
from her. Even a simple example in arithmetic at first rattled him,
although he was good in calculations. When he was forced to throw
light on his crime he not only became uncertain and mixed up ever>'-
thing, but quite uselessly he lie senselessly and against his
began to
own interest. For which are even now considered
his fraudulent acts,
more in the light of recklessness towards a much too gullible person
than as an actual crime, we had to consider him as responsible, but
as unfit to take care of his own afTairs. This was done with the
hope that the firm hand of a guardian might lead him into better
paths.
To be sure, instability is not rarely mixed with other anomalies,
so also with all grades of moral oligophrenia. Such a case is recog-
584 TEXTBOOK OF PSYCHIATRY \
nized by the following letter which is given as an illustration to show

how deductions can be drawn from written expressions:
Dear Mother:
Am Thursday in the hospital for the insane, Burgholzli
since last
(Ziirich), Ward Your loving letter before you left Hinwil was re-
B.
ceived and it has pleased me very much mother dear to hear that in
spite of my foolish pranks you have not given up hope, I thank you very
much for it, and I feel sure that better times are in store for us. I am
pleased to be up here, the food and attendance is excellent, I can also
amuse myself nicely so that time passes very quickly. I hope that I
shall soon be allowed to work. As I see from your letter you have
a sore foot, I wish you a rapid recovery so that you shall soon be
allowed to visit me. The visiting days are Sunday, Tuesday and
Friday from 10 to 11. When you come bring along Mr. Huber, I
would like to see him again, you know that he expected from me only
what is good. Dear mother send me next week a package with apples,
some chocolate, and some cigarettes, Camels 20 for 25 cents, one is
allowed to smoke when one has something to smoke, please don't forget
it, let me know how everything is at home. On the way from the
station to this place I saw Rosa Meier over on the Pfauen, she saw me
too, perhaps she told it to you. I hope dear mother that at least by
next Friday you will be able to walk again so that you can come to
see me. I always have a good desire for fruit.
In the hope of seeing you and a package, I am with greetings,
Your loving son Arthur.
The style is clear, intelligible, simple, and considering the degree

of education very good. The orthography, however, is not so good.
This difference usually signifies that the writer is not incapable of
learning and understanding, but that he did not have the required
zeal at school. The same is shown Arthur also in other things;
in
thus he does not know the number which one
of the Swiss cantons
hears so often that even very strong imbeciles can automatically repeat
them, but he is well able to recount in succession the cantons through
which one has to pass in 'a certain journey.
The expressions "loving letter" and "dear mother" in the text
denote that he is seeking an affective relation with his mother; this is
also shown in "I thank you very much for it," and in the mention
of the sore foot and in the wish for recovery. To what extent Arthur
actually loves and misses his mother cannot be quite definitely con-
cluded from the letter alone; however, one rather gets the impression
as a real emotional relation existed for her, and from his other
if
behavior towards her, we know, that he really still loves his mother
in a certain sense.
But how far does this love for his mother, his penitence, and the
good resolutions reach? He knows that he has committed foolish
acts; he is pleased that his mother did not give up hope in spite of
grateful to her for and he feels sure that better

that, he is very it,
here that
times are in store for both of them. It is important to note
does not at all enter his mind that it is up to him to bring about
it
these better times, that he has to work with himself, and that
he has
upon him by fate and the asylum; he
to take on a training forced
later fare better.
sees only the pleasant side of things, and that he will
nothing to say except about the excellent food,
About this place he has
and that one can amuse himself well. He then gets to his mother's
sore foot; he wishes her a rapid recovery but expressly for the purpose
that she should be able to visit him here ;he does not lack the neces-
sary associations in which he immediately tells her the exact visiting
times. But at the same time he would also like another entertain-
ment; he wants Mr. Huber; his mother is not enough for him so he
thinks of telling her that this man does not belong to the bad com-
pany which he otherwise "gets." Then he would also like apples,

in
chocolate and cigarettes; but he cannot wait until the mother
recovers
him these things and he even
the use of her foot; she should send
underlines the word send. How impatiently he expected this package
is shown in the hope he expressed later, that the mother should be
to be sent
able to come next Friday, whereas he expected the package
about things
even before. He would then like to show a bit of interest
not
at home, but here all further associations are lacking; he does
about the cigarettes he adds
inquire about anything special, whereas
meeting, but
the brand and the price. He then feels like telling of a
to his present position,
only as an occurrence without any reference
opportunity to show
whereas that could have furnished an excellent
whether he really was ashamed or not of seeing Rosa Meier who met
a reform school to a hospital. He then
again
him on the way from
returns to the hope of his mother's recover^-; but expressly only m
visit only in order
the connection that she visit him soon, and the
him the fruit, and not as a fulfilment of his yearnmg for
to furnish
This connection is repeated again in the last sentence
and
his mother.
emphasized, with which the letter as well as its purpose
is particularly
is ended.
From all sides the waiter thus returns again and again to the idea
of the pleasure. A certain affection towards the mother is ex-pressed.
also the recognition that he has actually hurt herby his behavior, and
that he will change for the better. But all this has only a passing
and secondary significance. The main thing is the pleasure, he thus
shows himself more and more changeable in affects, and towards the
most important things superficial, without persistence, always return-
ing again to his pleasures. With obliging and grateful mimic, he
always asks for something on every visit; now it is for some trifle,
now for his discharge. About the main thing, the improvement and
the measures and time required for it, that does not enter into his
head. As the young man is not without moral feelings, as his mis-
behavior was due to weakness, and not to direct impulses, and as he
is in some ways manageable in the asylum, the prognosis is not yet
very bad at his age, but only on condition that he will be confined
in the asylum for a long time. Corresponding to his instability, he
has until the present never stuck to work without being forced every- ;
where he ran away; a certain stability must be forced upon him in

part from without, and in part it may be expected by maturing his
character which is still somewhat childish.
E. Special Impulses
Among the impulsives Kraepelin includes the not quite regular

groups of squanderers, wanderers, and dipsomaniacs.
Frequently in spite of good intelligence, the squanderers simply
cannot at all manage pecuniary matters. Sometimes with great clever-
ness they contract debt over debt, ruining themselves and frequently
many other people with whom they come in contact.
The wanderers according to Kraepelin are restless people who do
not feel contented anywhere; they therefore cannot endure staying in
any place and move from place to place. It must be added, however,
that the pathologic wandering impulse is neither a uniform disease
nor even a uniform syndrome. Besides the types just mentioned there
are many others, e.g. the jolly business schemers; furthermore people
who find it pleasant in every place, but who ''soon become bored"
new
with it; most varied categories, who get into
sensitive types of the
trouble everywhere and hence run away; poriomaniacs, who through
hysterical, schizophrenic, and epileptic moods and unclear states, are
driven into the open.
The dipsomaniacs, no uniform category .^
too, represent
Kraepelin then also adds the gambling mania and the collecting
mania and brings the whole class in relation to affective epilepsy.
'" Comp. p. 351.
F. The Eccentric (Versciirobene)
The psychic life of the eccentrics lacks uniformity and correct judg-
ment. Awry conceptions of relationships, incorrect logical operations,
expression bring them out-
peculiar views and frequently also modes of
wardly near to the latent schizophrenics, from whom
they cannot yet
such types can also
be easily distinguished, although it is certain that
the only representative.^
be based on congenital anomalies. They are
of the constitutional aberrations in whom the afjectivity is apparently
not altogether or preponderatingly disturbed.
^"^
G. PSEUDOLOGIA PhANTASTICA (LiARS AND SwiNDLERS)
All the pathologic liars

from an exaggerated
and swindlers suffer
and planlessness of the
activity of their phantasy with unsteadiness
flowing tendencies, vanity m
will. Always in the sense of their high
they think them-
any direction, irritability, ambition, and sexuality,
and roles that, forgettmg the un-
selves so well into fancied positions
structures, they allow their actions to be determmed
reality of these
at their disposal they
by them. If they have no strong moral feelings
and swindlers. For
must naturally degenerate into panhandlers
hysterical symptoms is very
conceivable reasons a reenforcement with
frequent but not necessary
.^^ It is remarkable that on two occasions
of actual psychoses
I have seen the syndrome appear as a forerunner
(paresis and dementia pra?cox) in so
pronounced a way that for a
long time I overlooked the main disease.
Henneberg's ^"^ patient who and

studied theolog>'
Illustration:
assumed the title of
law for some time and also solved a price problem,
bureaus, bought
''Dr of Jurisprudence," quickly opened many business
with money obtained fraudulently. He
dictated
a big rapid press, all
however, send out,
many fictitious business letters which he did not,
money for theatre tickets, which he gave away as
and wasted much
seemingly free tickets.2*
H. Constitutional Ethical Aberrations

moral oligophrenics, moral
(Enemies of society, antisocial beings
idiots, and imbeciles. Moral Insanity.)
beings represent, to be
Enemies of societv, asocial and antisocial
The inclusive term is only
sure, pathologically no uniform
class.
^" See pp. 108-9.
-zSTorenslchen und klinisch-^n Beurteilung der P^ûdologia phantastica

375. Ref. Zentralbl. 1. J.
en-enheilkunde und
Chante-Annalen. XXV. Jahrg.
Psych. 1902, XXV. Jahrg. S. 2S2.
*'*
For further example, see pp. 108-9.
held together by practical and social viewpoints; various predisposi-
tions may lead to crime. A good picture of the varieties of criminals
is given to us by Aschaffenburg.^^ The chance,
affect, and oppor-
tunity criminals are really not such bad people; they go off the track
under the influence of a situation which they cannot control because
of changeable feelings, lack of reflection, slight moral weakness and
similar defects. It is for this reason that Aschaffenburg conceives
them as criminals of the moment. The chance- criminal does harm as
a result of carelessness, the affect criminal can kill or injure his ad-
versary as a result of just indignation or rude excitement, while the
opportunity criminal may steal from the bank when he finds himself
in any financial distress. The real criminals in increasing degree of
dangerousness commit individual crimes with cold reflection {pre-
meditated criminals) the recidivistic criminal allows himself to be
;
drawn into many such acts, but is able,however, to work again in the
intervals with relatively good will and can generally behave quite
honestly. The life of an honest man is altogether incompatible with
that of the habitual criminal; nevertheless it is due more to negative
motives that the latter remains a criminal, e.g. distress, when he has
been out of work; but he prefers the not to steal to the not to work.
The professional criminals have positive impulses to crimes as such,
which they perform like the violinist his art; they live on crime only.
There are many specialists among them, e.g. the house burglars, the
pickpockets, etc.
It is quite obvious that the first three classes frequently show some
lack of morality, while the others lack something of it. However the
ethical defect is not the only, and frequently not even the essential
factor in their aberration; they are just as abnormal in so many other
directions: they may be unstable, weak, labile, irritable, eccentric,
unclear, debilitated, etc.
The degree of dangerousness depends among other things on
whether, and in what degree, the anomalies, especially the moral de-
fects, are associated with positive bad impulses and especially with
activity. The merely heartless person will cause pains to others if
he can gain some advantage thereby; but he who takes pleasure in

the pains of others will make a direct effort to torture his fellow
beings, even no use to him. One can steal out of sheer lazi-
if it is of
ness and out of a lack of moral feelings, or out of positive pleasure in
gaining a livelihood in this way. In every case all these people in
time take an attitude against society, which defends itself against
"^Das Verbrechen und seine Bekampfung II. Aufl. Heidelberg, Winter, 1906.
S. 179.
them by reprisals. Many finally conceive them.selves as pioneer

fighters forfreedom and justice against a hypocritical and violent order
of society. A dread of orderly work or at least a lack of a persistent
capacity for work is common to almost all the various kinds of criminal
natures.
The intelligence of the antisocial beings is very diverse; it is more
frequently bad than good; many of them are more eccentric than
stupid. That a lack of moral affectivity will cause difficulties to think-
ing in ethical spheres is self-evident. There is perhaps a uniform
quality which manifests itself as moral impulse and as moral under-
standing, in the same way as the impulse for music or mathematics is
preferably associated with special endowments. Agood moral under-

standing and a good development of social feelings would then have
to occur together or be absent together.
The moral defect is as a rule congenital and also inherited, even
though as a result of brain injury there may arise not only irritability,
but also a certain lack of consideration for others and even a pleasure
in teasing. In milder cases the patient may improve somewhat in
proper environments, but hardly after the twentieth year. However,
one should not forget that in children even repeated criminal acts, quite
apart of those caused by the milieu (stealing among the Spartans, or
at the command of foster parents) need not always be a sign of a bad
development of the moral feeling. Such people who are simply spoiled
by the milieu are in a measure still educable,
A great many asocial beings show already in youth the type of
mind that they will represent later. A great many of them are back-
ward in school even if the intelligence is good, because they do not
adapt themselves sufficiently, and show too little diligence or attention.
In rare cases one finds unusual accomplishments in a single direction.
Many are lazy, inclined to steal, and to lie, they are cruel to animals
and human beings, they are full of demands, and either through inten-
tion or neglect they spoil their own belongings and those of others,
they are vain, unreliable and egotistic. They cannot yield to authority,
and run away when something does not please them; punishments are
not feared; as a matter of fact neither cake nor the whip produces
any visible effect. In putting through some bad pranks they develop
cunning and energy, they rapidly learn from others the bad things, but
with difficulty or not at all the good ones, and instinctively seek bad
company. A premature sexual impulse in normal or perverse direction
is almost always the rule.
How logic becomes weakened in the same sphere with the moral
feelings is given by Hanselman in a typical example: An apprentice
comes home late at night and soils his bed and Sunday suit by vomiting
and is reproached for it by his master. He then related it and added
impudently: "A master who calls me lousy is no man for me; he has
not learned any manners." Here we see at first quite a different esti-
mation (in the main affective, but also intellectual) of his own action
and that of the master, then a lack of associations in a manner peculiar
to oligophrenia: The patient does not understand that the situation
demanded the calling down. The first error gives force to the mean-
ing of the other. As severe as such going off the track seems, yet it
does not alone prove the deep antisocial disposition. The suggestion
of the environment, the attitude towards society and its organs can
in itself produce such logical jumps. (Compare the war attitude of
whole nations.)
Many of these children are physically malformed in some way;
they show many "stigmata of degeneration."
Aside from the types described in other places as the unclear,
unstable, and pseudologs, who often become criminals, there is one
group under the various types of asocial and antisocial beings that
can in some measure be differentiated. I refer to those in whom the
feeling tone of all ideas concerned in the weals and woes of others is
stunted {moral imbeciles) or is entirely absent (moral idiots) both ;
groups together would be designated as moral oligophrenics.^^^ Sym-

pathy with others, instinctive feelings of the rights of others (not one's
own) is absent, or is inadequately developed. At the same time the
other kinds of emotional feelings can be perfectly retained, or likewise
can only be affected in a certain degree, for the absolutely apathetic,
the "unemotional" naturally do not become dangerous criminals. How-
ever, the degree of danger varies greatly; it depends on the existence
of bad impulses, and the vividness of the activity.
Until now I have never seen moral oligophrenia without finding a
qualitatively similar defect in the nearest relatives, mostly in one of
the parents, althoughit is not always easy to show it. Moral defects
appearing after brain injuries or in mild schizophrenia have quite a
different character.
*" As moral insanity Prichard designated some time ago diseases in which the
"moral" factor in the broad sense of the English expression, seemed to be

affected. Such patients acted wrongly although no confusion of thought was
demonstrable. This included in the first place the submanias (folie raisonnante
of the French), then also the obsessive impulses and other diseases. German
psychiatry adopted the name in the sense of a defect of the moral feelings.
Both the name and the concept have become discredited because they had been
manifoldly abused practically and theoretically. The concept should not, how-
ever, be dispensed with in psychiatry, because it designates a definite disease;
but everj'body agrees that a substitute should be found for the name.
Peculiarly enough there arc still some people who for dootrinary
reasons maintain that there are no such moral defeft.s without in-
tellectual weakness, which must be the basis of thf; badly developed
morality. Well, one can naturally find in every man, and still much
easier in one otherwise already in some way defective, some slij^ht
deviation from what one calls normal. But such intangible finding
actually proves nothing; just as little is proven by the fact that among
the criminals who allow themselves to be caught one finds a great

many moral defectives. It is quite certain that the moral state has
no relation to the height of intelligence, that there are intellectual
oligophrenics with a well developed moral sense, and that one meets
moral idiots in whom one can demonstrate neither any other kind of
pathologic disposition, nor a mental disease, nor any explainable
intelligence defect; but one must not look for the latter in prisons
only.
Moral idiots form the neucleus of Lombroso's concept of the "born
criminal." The latter embraces, however, in unclear association also
other criminal natures, e.g. the excitables and unclear ruffian or people
with epileptoid characters. The author has moreover asserted many
strange theories, like that of the "reo nato," who is a sort of latent
epileptic, atavistic, and like the child. But only a small part of the
born criminals in any way resemble epilepsy; about atavism in man
we know nothing, and it is absolutely false to confuse the tendency of
a murderer with that of a primitive warrior, that of the thief with that
of the normal from an environment which has another sense of
property. Nor is it true that the born criminal is like the child. The
normal child has altruistic feelings as soon as it can express itself in
this direction; the only thing it does not understand sufficiently is the
complication of the relations, so that the feeling tone must be absent
in some situations where it would manifest itself without anything
further in adults who examine the magnitude of things from all
sides.
Despite these weak spots and its poverty in logic Lombroso deserves
great credit for having set going the study and treatment of the crim-
inal in place of the simple repression of the crime. Thanks to him.
there is at least a more general demand for a change in the criminal
codes, which are quite inadequate for the present needs, and the way
is being paved for a general improvement.
I. The Contentious (Pseudo-litigious)
The fighting maniacs stand between those who feel in the right and
forever appeal to the law, on the one hand, and the paranoid litigants,
on the other. This middle form cannot be differentiated from the
former; but is quite definitely separated from the other by the facts
that although it leads to false conceptions it never attains the form
of a real delusion, that the disease does not continue to progress, but
that itsimply the temperament that leads to many fights which
is
need not necessarily be connected with one another and cannot be

given up, when the patient finally recognizes the uselessness or some
of the dangers of a certain fight. Unimportant as well as important
differences equally involve the whole person, for the patients are too
sensitive to have any feeling and understanding for the rights of
others. All acts of others running counter to their own demands they
conceive as malicious, or as personal insults. Their character shows
an enhanced feeling of self, "a mixture of sensitiveness, regardlessness
and arrogance" {Kraepelin). Their own affair they feel as the
very affair of justice and they consider it a ''duty" to carry it
through.
The understanding of the patient varies, but most of them have a
narrow field of vision, and with it a certain cunning and strong alert-
ness. Like in all affective people the memory is disturbed in the
manner that the experience becomes changed in the sense of the
patient's feeling of self.
The "development," if one may speak of such in this disease, varies.
Through constant fighting with certain neighbors who give tit for tat,
the patients naturally merge into an incessant state of irritability which
makes their anomaly look worse. Transference into more favorable
or especially into new circumstances gives them peace for some time.
To be sure, they regularly neglect their callings. Probably for ex-
ternal reasons it almost always involves men; women of similar
character live through it in quarrels within the family.
The theoretical difference from the paranoid forms is very char-
acteristically compared by Kraepelin with the difference between the
traumatic patient, who as a result of a single experience remains so
constituted that he must feel sick, and the hypochondriacal patient
who now discovers that, and now this sign of disease.
The recognition is in most cases not difficult, but its differentiation
from the normal is not easy. Some of the people so designated show
manic moods of a chronic nature. These differ, however, from others,
mostly by a certain kindness which becomes mixed in all quarrel-
ings. They are able under conditions to speak quite well of their
enemies and become reconciled to them after the worst kind of
brawls.
XIV. OLIGOPHRENIAS (PSYCHIC INHIBmONS OF

DEVELOPMENT)
The study of the associations and memory have shown us that
^"^
the brain or the psyche holds so firmly the individual experiences
as well as their connections, that whatever is experienced simultane-
ously or in immediate sequence forms a uniform memory structure
which can again be ekphorized through every individual engram. Thus
certain classes of engrams, simultaneously acquired, form associations
with one another. Associative connections of a different kind are
also formed between new and former experiences and then between
the same ekphorized engrams, and thirdly, the memory pictures are
brought into connection with one another in memory and thought.
The formation of engrams varies comparatively little. Most animals
have a memory, but in principle it is obviously only for those experi-
ences which they can use. Idiots form engrams of everything. But the
development of the associative connections fluctuates within the widest
limits, we may say, from the animal and idiot, to the genius, for in-
telligence depends chiefly on the manner of the possible associations.
Hence in the pronounced psychisms of inhibited developments we
deal, as it were, only with a want of associations. ^^ Wherever the
poverty of the same inhibits the progress of the person, depending on
the degree of disturbance, we speak of idiocy, imbecility, or debility,
morbid pictures, which Kraepelin comprises under the name of
oligophrenias. The parallel expression "psychic inhibitions of develop-
ment" is a misconception. Intra- and extra-uterine brain diseases as
well as other things may result in the same poverty of the possibilities
of associative connections as in inhibition of development in the struc-
ture of the brain.
One must, however, sharply distinguish jrom the brain develop-
ments, the development of the psyche, or the acquisition of experience
material in childhood, without which the most endowed structure would
remain sterile. With the help of the associative connections, the indi-
vidual engrams of the sensations are raised to concepts and ideas by
the childish psyche. This "psychic development," the gathering and
*" Individual experiences range from the simplest sense perceptions (green,
flat form, the position on the plant, etc., which make up the concept of leaf)
to individual actions which in their totality form a complicated scene.
**The possibilities of psychic connections must naturally depend in some way
on the number of the anatomical elements in the brain; however, 0114: does well
not to bring into relation the process oj association with the aneitomic ''associa-
tion systems" oj the brain.
arranging of experience material, naturally becomes insufficient when
the receptive organ is disturbed. All oligophrenias are, in this respect,
inhibitions of development.
Moreover, some also think, more or less clearly, that just as the
physical strength continues to grow after birth, the same holds true
for the psyche as far as its disposition is concerned; that normally
it progresses during the whole of childhood while in the oligophrenics
it "remains still." If we disregard the training of functions, this idea
is quite confused, and, in part, certainly false.
Such a development has nowhere been comprehended on a purely
intellectual sphere. On the other hand, we are familiar with the fact
that the emotional lability and the fiightiness of volition observed in
the child become transformed into the more stable feelings and
definite objective desires of the adult. To be sure, there are some
quite rare forms of diseases designated as "Infantilism" which retain
the infantile characteristics, but such grown-ups show a very marked
distinction from real children. Besides, infantilism as such does not
by any means represent a clear cut picture of a disease. It is often
mixed with signs of mental debility, with sexual abnormities in which
the sexual aim manifests itself in playing instead of in the sexual act,
and in an unchildlike impulse to "play" the child.^^
To be sure, one frequently speaks erroneously of a deficiency in
intellectual development. But if an imbecile attains the level of an
eight year old child and stops there, it does not signify that this "stop"
is due to the fact that the ontogenetic development pro-
essentially
gressed from birth to this point and stopped, but it means that the
capacities possessed by the patient from the very beginning suffice
to elaborate the material into such a complication as one would put
before an eight year old schoolboy. Again it is quite another matter
if a hitherto normal child becomes afflicted with some brain disease
and then cannot learn anything more complicated, remaining, as

it were, at a standstill. But here we deal with a child who was per-
manently intelligent, who became permanently stupid.
Oligophrenias differ from all other mental diseases through the fact
that as a result of insufficient assimilation of empiric material, scanty
and inadequate ideas and concepts are formed in childhood, and that
as a resu'.t of a permanently existing poverty of the associative con-
nections, even the actual em^piric material cannot be adequately
elaborated.
Although in the oligophrenias we deal with a general disturbance
of the cerebral cortex, the weakness of intelligence alone stands out
=""
Cf Hirschfeld, Sexualpathologie, Weber, Bonn,
. 1917, p. 29.
as the principal symptoms of these diseases. For the weakness of

intelUgence not only of the greatest practical importance, but the
is
very cerebral anomalies that come into consideration represent in a

certain relation quite a uniform simplification of the intellectual
apparatus, whereas other functions like the instincts and affectivity
need not necessarily be affected, or even when deviating from the
normal they radiate into the most dissimilar directions and show
nothing that is typical of imbecility. As a matter of fact, affects
like euphoria or anger are the same in the genius, in the idiot, and in
the animal, at least as far as we can observe, whereas the intellectual
functions show colossal quantitative differences.
The oligophrenias comprise not only the congenital disturbances
but also those that were acquired in early childhood. Despite the
multifariousness of all these diseases there are many good practical
reasons why even science should not be satisfied with such a summary
judgment. The weakness of the associations and the existence of the
disease during the bringing up stamp the whole group with something
characteristic symptomologically, and what is more, with something
of common practical importance.
The oligophrenias are, in part, simple aberrations of the normal,
and even in cases where a definite morbid process produces the mental
weakness it may be hardly perceptible. The pathological group can-
not therefore be separated from the normal into which it gradually
changes through mental debility and narroivness or through stupidity.
But even within these entities there are only fluctuating transitions on
a psychic basis.^" One designates as idiots in a general way patients
of a higher degree who cannot acquire any school knowledge or
who are absolutely unfit socially; as imbeciles patients who do
not advance beyond the position of common school graduates, or
those who can still mix in human society and can even perform some
subordinate services, and as mental debility one diagnoses those who
come to a standstill in the development after the public school or
who in simple relationships can still maintain themselves somewhat
independently; that is, they fail when confronted by the average
demands. Debility is of little medical, but of greater forensic
significance.
Other criteria with marked limitations are really of no value, for
the simple reason that the various spheres of intelligence may attain
different heights in the same patient. Idiots are supposed to be indi-
viduals who are unable to talk, or who are unable to execute a verbal
""The etiological anatomic division is quite diffarent; here one can see a
great number of distinct pathological pictures.
;

order, or who show pronounced physical deformities. If is quite super-
fluous to say of imbeciles: "That, as a understanding oi
rule, their
numbers hardly goes as far as ten, when the patient can learn to count
mechanically even up to 100." Sollier as well as Ziehen make a moral
distinction between the two classes in favor of imbecility. This is
contrary to all facts; imbeciles may be morally as high as they are

defective, and idiots as malevolent as they are kindly. The only
difference lies in the fact that the lighter grades, the imbeciles, rarely
come to the physician, while the idiots are always in need of care.
Some often obtain a scale of the grade of imbecility through a
compaiison with children of a definite age. Thus a patient is said to
have reached a level of an eight year old child, and with the Binet-
Simon ^^^ test one can really delude one into the formation of such a
parallel. But one must remember that the child has an enormous
advantage over the imbecile, as it quickly learns more new experiences
it has the paths for new understanding and all he needs is to bring
them in contact with experience. On the other hand, the imbecile

has the advantage of having numerically more widespread experiences
which thus enable him to move about more freely, as, for example,
to make a journey, or do some work, in which the child is still helpless.
The intelligence of the normal child is therefore never on the level of
the imbecile. Certain complications of thought are still inaccessible
to the child because it lacks experience, while in the case of the
imbecile the complications of thought are lacking because he is deficient
in the capacity to absorb complicated experiences.
Symptomatology. Idiocy can be recognized without any difficulty.
The treatment, too, is more in line with nursing and education than
medical interference. It would, therefore, be superfluous to give here
a more accurate description of severer forms, and the subsequent
psychopathological remarks will be devoted, in the first place, to
imbecility. Still whatever is said of the latter is also true of idiocy, if
the defects are markedly exaggerated, and of mental debility, if the
defects are minimized.
Perception and apperception are little disturbed directly through
the diminution of the association of ideas, whereas complications
naturally often produce severe injuries. The brain disease which is at
^The idiot was also compared to an animal, and was .said to evince an
"animal-like dementia." Of course, both an animal and an idiot have smaller
capacities of association than the normal person, but the animal brain is a
simpler machine excellently adapted for the required situations, whereas the
idiot's brain is a more complicated but unsuccessful or spoiled apparatus which
has an insufficient adaptive capacity. A chronometer does not sink to the level
of an hour-glass just because it is badly constructed or because it is spoiled.
the basis of oligophrenia is very frequently connected with disturbances

of the senses, especially that of hearing, which not only affects per-
ception and apperception, but also extremely retards or makes even
the whole psychic development impossible.
Oligophrenias which are not complicated by diseases of the sense
organs often show some dullness of the sensations; in any case the
perceptions are often correspondingly somewhat retarded. The thresh-
old of differentiation is as a rule quite high in all spheres. Some
patients never learn to know perspective or pictures in general; thus
a compass is a globe, and an hourglass is a bottle. They do not
understand scenes pictorially represented because they see only the
detached elements. They see "a man holding the hand of the other
who is in bed; here stands a man," but they cannot see the connection
of the elements, namely, a physician at the bedside.
Association of Ideas. The oligophrenic has not the capacity to form
the necessary number of associative connections and what is some-
thing different to
keep them in mind simultaneously at a given
moment. He thinks more in unelaborated sensible terms than the
normal person, and he thinks only of customary things which fre-
quently occur, and of simple matters which require few associations.
He abstracts poorly, i.e. he forms only simple concepts, some of which
are incorrectly abstracted, but he is not able to form any abstraction
in the specific sense. Nor has the oligophrenic the capacity to separate
ideation complexes once formed; that is, he has no ability to "reproduce
in different order the material formerly acquired" (Hoche).
Ignoring that which is not of frequent occurrence and making
better use of customary material causes a kind of insufficiency of
memory. This is, however, only secondary and the actual defect lies
only in the lack of associations. The latter may simulate under
certain conditions an absolute memory defect, as when a spider jumps
on the head of a nail many times in succession. This is not because
the spider "forgets" that the nail head is not edible, but because it
cannot distinguish this particular black spot from other black spots
which usually represent flies. To react to it differently than to flies
the spider would have to perceive its particular qualities or to associate
it then with the details of the environment. Both conditions require
many associations.
Yet to a certain degree the number of associations can be replaced
by the frequency of the experience. Thus the perceived details of the
nail-head or the individual sensations of the environment may suffice
to form a distinction even where there are relatively few associations,
if the sensations are constantly repeated in a way that now one.
.598 TEXTBOOK OF PSYCHIATRY
now another detail will become firmly associated with the edibility.
To be sure, an animal rich in association will acquire right at the
first experience the connections necessary for the particular purpose.
all
Accentuating the characteristic elements, the abstraction, as discussed

above, is also facilitated by a repetition of the same experience, i.e.
many most
repetitions of similar experiences will perforce develop the
characteristic elements. That accounts for the fact that the customary
material is always more realizable even where there is no question
of facility of memory in the sense of practice.
Another example would be the case of an oligophrenic who repeat-
edly allowed himself to be duped by the same or similar April-fool
jokes. His associations centered only on the joke, but he did not con-
nect his new experiences with the idea of the critical day. Under
certain circumstances he was also unable to form sufficient abstrac-
tions to distinguish the jokes from what was intended to be serious.
However, when the same joke was very frequently repeated, the
deception finally and the weak-
did bring about the association,
minded patient became where
suspicious, even
he should not have been.
The effects of the memory therefore depend on the number of asso-
ciative connections, altogether regardless of the fact that ekphoria gen-
erally is easier, the more association paths it has at its disposal.^^^
Moreover, the poorer the associative connections, the more repetitions

are necessary before the psyche can utilize a complicated situation
through memory. Hence it is mainly the everyday events that come
into being in the oligophrenic; he is unable to use in his reflection the
uncommon material.
The poverty of association impedes the formation of concepts
because the latter naturally require a combination of many actual
experiences, and what is more, they must be not only of the present
but also of the past.^^^ The more abstract a concept the more com-
binations must be made. That is why there is an absence of higher
abstractions. Many concepts are also falsely formed because the
essential is not differentiated from the unessential. For the essential
element is which constantly repeats itself in the various
either that
experiences which are composed into a uniform concept, or subse-
quently that which attaches to itself the fundamental deductions.
Thus the (popular) concept of "leaf" is held together by the
flatness of the structure which grows out of a plant, whereby all the
other attributes can change. In the concept of "poison" the common
element is the destruction of life resulting from taking it into the
=^Cf. p. 31.
'" Cf p. 13, etc.
.
body. Whoever does not connect together all the more important
experiences of leaves and poisons can never have a correct concept of
these things. What is more, a great part of the concepts is not inde-
pendently separated by the child, but is brought about by language.
This particularly necessitates many associations and accounts for
the fact that imbeciles find it difficult to take over strange concept.s
and to correct their own in speaking with others. The abstraction
represents also a separation of the ideas from the ordinary concrete
material. Because inhibited, the ideation material consists in only
too much of concrete individual pictures instead of an elabora-
sum of ideas. But if some general concepts are once formed,
tion of the
owing to their easy accessibility (similar to those in organic cases),
they are very frequently used where they are inapplicable (e.g.
"implement" instead of "shovel").
The separation of the ideation complexes can take place in the
positive or negative sense: The detailed experience, as for example
the green color in the concept "leaf," may be dropped, for there are
green and other colored leaves, or it may be emphasized as the
essential distinction, like the characteristic form of all oak leaves,
through which the detail is recognized. The separation is effected
through new experiences. Thus if one has seen green leaves only,
then the form of the leaf as well as its position on the plant become
firmly associated with the color green. One only imagines green
leaves. But then one notices a red leaf. He who possesses many
associations of ideas will still associatethe idea of leaf with its
form and position, but he now has besides two separated ideation
complexes, one with the green and the other with the red color
component. Following the usual laws, the second will inhibit the
first in so far as it disagrees in the partial component with the idea
green; the latter is therefore "separated." If, conversely, in many
oak leaves the form is always repeatedly perceived, despite such
differences in size and color, we then say that in the concept complex
"oak leaf" the figure is accentuated and separated from the general
concept of the leaf. On the other hand, the imbecile does not view
simultaneously the structure of color, form, and position, and there-
fore shows a tendency to ignore some individual components and to
overestimate others. If one of them, let us say the color green, made
a special impression on him, then the red leaf will not stimulate in
him the association of the green leaf. The two experiences continue
side by side disunited without influencing each other, or he may ignore
the color and then fuse them into one concept, but it does not come
to his consciousness that there are green and red leaves. In both
cases the structures as a whole remain stable. But to single out indi-
vidual components from the sensation complexes is as important a
fundamental condition of concept formation as putting them together.
It is also an essential part of the process of abstraction and at the
same time one of the fundamental conditions of reason.
The difficulty in differentiating the structure, owing to a lack of
understanding of the important element, explains the apparent con-
tradiction that on the one hand the patients often cannot associate
to an individual quality despite the fact that frequently they repeatedly
stick to a mere partial manifestation. The patient takes all men with
yellow buttons as policemen because he was unable to form the correct
concept of a policeman, and the buttons have especially impressed
him; he can associate only to them; on the other hand, he is not able
to distinguish between a beech leaf and an oak leaf because he is
incapable of isolating the individual quality of the various formations
of the borders.
Experimental Associations are so very characteristic in the oligo-
phrenias that they can be used for diagnostic purposes. But a more
precise examination can be done only in the torpid forms.^^* The
retarded course of psychic reaction can be measured here, because
even with perfect understanding of the experiment and without stupor
the reaction time may be prolonged to double. The poor capacity for
abstractions is shown through the fact that the patients find it hard,
indeed, for the most part they are altogether unable, to respond
to the stimulus with one word. Words and concepts occur in life
only in association and can only be isolated artificially. This cannot
be done by torpid oligophrenics, and accounts for the fact that
instead of an isolated concept they express a whole idea. Thus the
stimulus word "to light" brought the reaction "The baker lights the
wood." But they do not even grasp the stimulus word as a separate
concept, but something like the question: "What do you know
about . . .
?" or "What is the meaning . . .
?" As the only similar
experience happened in school they easily confuse the new situation
with the one in school and often answer according to the rules,
examples, and phrases studied there, even if the answer is quite incor-
rect (Winter
consists of snow). As they are unable to associate to
a mere word, and must put everything in one connection, their inner
associations are more numerous than in an intelligent person. The
'^*
Wehrlin, Uber die Assoziationen von Imbezillen u. Idioten. Diss. Ziirich
1906. Also Jung u. Riklin Diagnostische Assoziationsstudien, Barth, Leipzig
1906. For the general application of the association experiment in mental cases
as used by the Ziirich school see Chap. VIII of Brill's Psychoanalysis, Its
Theories and Application, 3rd Ed. Saunders, Phila.
THE INDIVIDUAL MENTAL DISEASES GOl
content is especially rich in explanations and above all in definitions
of the concept mentioned by the stimulus word. The following will

Lamp to light; prison consists of cells, where one
illustrate it.
locks up useless people; head part; war when two countries fight
each other. The explanation may also be given through examples:
wreathyou see it at the Turn festival; sick I was already sick;
father he threw me once down the stairs.

The poverty from the many repetitions in content
of ideas results
and form, which are frequently applied where they do not fit; the
stimulus word may then be replaced by a synonym or it is slightly
varied (cat kitty). Frequently an expletive serves for a great many
answers. This is especially true of the word "man" which in the

intelligent person is, so to speak, a complex indicator, but serves here
frequently to conceal the poverty of thought (head the man; swim

More frequently than healthy persons, the
the man can swim).
at all, and this is especially the case
oligophrenics find no associations
in somewhat unusual words; no reaction does not always mean that
it is merely a question of an emotional stupor. The vagueness and lack

expressions frequently
of clearness of the concepts and manner of
come to light in the most dramatic manner: (wedding serves for
amusement; familywhere many children are; grandmother older
tree component part; star
mother; sweetwhen a girl has sugar;
The insufficient removal of the idea from the
a part of heaven).
concrete material is also sometimes seen, thus: To sing consists of
the patient (emo-
notes and song books. The slight bewilderment of
through various peculiarities.
tional stupor) often expresses itself
naturally impossible to describe the whole oligophrenic dis-

It is
turbance of intelligence, and especially all its infinite
varieties. Some
of the various principle functions.
examples should illustrate the defects
The patient knows of Christ only
The Adhesion to the Concrete:
what he saw on pictures. (Who was Wilhelm Tell?) "We have
played him in the neighboring town; masked women

and children
were there too." Or: "One Tell is put up in Altdorf, and now still
you know the three Confederates?)
another statue in Burglen." (Do
"0 yes, there were three men who raise their hands high and stretch
their fingers so." The difference between Catholics and Protestants
fact that the Catholics have Christ on the cross
standing
consists in the
on the (Where does one go when he dies?) "In the cemetery
streets.
there a new church."
near the church in Seebach. They have made
(What is this? [picture of hedgehog].) "Don't they prick? One was
customary thinking the normal
on our ground in the fall." Even in
mostly utiUzes elaborated ideas which are distinguished from

person
the concrete. He thinks of a certain person as a brutal character,
whereby he does not have to know whence this idea originated; to
the imbecile he is that person who gave him a beating at a certain
place.
The Inability to Get Away from the Customary: (How can you
divide an apple for three persons?) "You make four pieces, give one
piece to each and one remains." ^^^
Bad Formation of Abstract Concepts: ''Helvetia is the woman who
is copied on the coins, and always walks around Switzerland to kill
those who wish to harm it." "Freedom is when one has no debts."
"Religion is when one goes to church." To be sure, such defects are
not seen at their best in the provoked definitions, which even in the
healthy person do not exactly correspond to what one wishes to con-
vey, but in the occasional use of such concepts. The patient speaks
of justice, but understands by it only the deserved punishment and
not also the merited reward; he speaks of religion and includes in it
the fact that he came to his meal at the proper time. Or a patient
speaks of states and territories and mixes them with cities, towns,
and countries, showing that he has no clear concept of either a state
or territory, and that his knowledge of a city or town is only fair.
Poor Abstraction Capacity: The patient has learned to calculate
by means of match sticks but is unable to do the same problems with
eggs. He writes: "In the garden the weather is always nice"; he
isunable to imagine the idea of garden when he is not in it. A short
story read, as, for example, a fable, he often relates in the subjunctive
mood, because he cannot have read that.
rid himself of the idea: I . . .
If one questions him concerning a from a complex of

definite detail
ideas, the patient is then altogether unable to answer only this
question. He is forced to bring in the whole connection and thus
sometimes fails to answer the question either directly or by impli-
cation. (But how were you annoyed?) "Because I am just con-
servative. ..." This was given to the question as to the relation of
the conservatives to the liberals.
Just as oligophrenics are unable to disregard a greater complex
of ideas, just so are they unable to bring a new idea into new con-
nections. The patient can count, i.e. he can say correctly the numbers
in succession, but despite all effort he cannot actually be made to
count also his own fingers. One of Kraepelin's patients has learned
to cook quite well in a bigger kitchen, but when she was later in
another home of only three, four people, she served just as many
^"Cf. also the example of the driver who didn't think to drive around a
stone lying in the street but beat the horse, p. 82.
.
eggs as she formerly did for a whole round table. When the patients
are confronted with new tasks, or when they are transferred to a new
environment, the thoughts in many of tliem almost stop (emotional
stupor)
Frequently the patients grasp even all the details of the stories
they have merely heard, e.g. the story of Wilhelm Tell, but cannot
reproduce them without help, because the logical connection has not
become clear to them. Some form quite incorrect combinations:
Moses fed five thousand men on the Mount of Olives. (Who was
Peter?) "He crowed three times." Where vivid phantasies exist
very characteristic additions and distortions are often made up:
Gessler put a pole right across the street, Tell was to have walked

under it. The people who killed Christ were uneducated. The for-
bidden tree in paradise bore poisonous fruit, and Adam was punished
because he would not go to the tree.
Low grade imbeciles cannot understand a clinical examination
(They are here "to give information").
Next to great Gullibility, there is still a greater inability to pick
up information. Only in simple things do oligophrenics become wise
through experience. For they really do not understand the connections
and do not know what the problem is. Nor can they transfer one
experience to another even if the situation is similar. Instruction is
also hindered because the patients are not aware of the limits of their
knowledge, e.g. they believe that they know everything.
A servant girl considered it when
she was told to put
a bad joke
her savings in a bank. She thought that no one could be so stupid
as to pay her something for being obliged to take care of her money.
Another defective could not be convinced that a certain foreigner
was not weakminded because he mispronounced some sounds and
because he used expressions different from the vernacular used ex-
clusively by children and imbeciles.
Many of these persons are altogether unable to grasp that an
answer must be correct.^^^ They answer at random, nod afl&rmatively
to everything that they do not understand, etc.
Particular difficulties are encountered in comparing and differenti-
ating. The more extreme defectives cannot at all understand questions
of differentiation, such as what is greater? which would you prefer?
To many it is impossible to put a question theoretically. Thus to the
question, If your mother wêre dead, who would give you food? the
answer was "But my mother is still living." Or to the question. If
you buy a coat for $36, how much change will you get from 50?
"* Like children in their first years and primitive people.
the answer was "$15," upon which the patient insisted, because he
once bought there a coat for $35 and received $15 change. Or, a two-
dollar bill than a one-dollar bill and two halves of a dollar,
is less
because one "must change it and one then gets too little back."
Judgment and Understanding of things and relations are naturally
insufficient, and that accounts for the mistakes which rapidly increase
with the complication and unusualness of the objects to be judged.
Except in the very simple combinations, such as stealing and getting
a whipping, the patients are impeded when it comes to include the
past and take account of the future. Higher points of view are
naturally not formed and not understood.
Some milder imbecile can still acquire some Vocation with the
necessary practical knowledge. A peasant may be able to do the
farm work correctly, but in maDiy things he is unable to say why it is
done in this way. The imbecile can do much more than he knows
in contradistinction to the normal child, where the reverse is the case
(Kraepelin) . At all events, the capacity for practice in all things is
mostly very slight.

Hoche aptly enumerates the intellectual peculiarities of the imbe-
cile as follows: "He is paltry, sticks to one thing, perceives concretely;
he is inconsistent and dependent in the conduct of life ; he overestimates
his own personality, shows a strong development of the egoistic in-
terests; he is gullible and shows a slight resistive capacity to the will
of strangers and to his own, and eventually evinces abnormal impulses,
2^^
etc."
Not so seldom the intelligence shows itself quite unharmoniously.
There are some gaps, which are not, however, very striking or then
there are special gifts, as for music, mathematics, for the observation
of the weather, for good optical perception and reproduction in
An imbecile was able to draw the Strassburg
drav/ing, painting, etc.
Cathedral with hundreds of details which he has seen only once years
before.
The Mode of Expression of imbeciles is naturally awkward and
depends on the degree of the deficiency. Most idiots show a marked
weakness even in simple grammar, and in the highest grades speaking
ceases altogether. Some, even the more intelligent, never learn to talk,
although they hear and understand (auditory muteness). Imbeciles
speak in a circumstantial manner because they are unable to pick out
and omit the unessential, and show a preference for familiar phrases.
Orientation as to Place and Time continues to be good, in so far as
"' Binswanger und Siemerling, Lehrbuch der Psychiatric, 3rd Ed. Fischer
Jena 1911, p. 224.

the patients are able to perceive such relations. Many wander about
far without losing their way. Not all these patients are in position
to judge time correctly. In any case, most of those who are at all
familiar with numbers have a concept of an hour, day, and year. If
one should no longer be able to differentiate between day and night
he would certainly also be so stupid that no kind of understanding
could be had with him.
Bad is often the orientation as to position which they sometimes
judge quite falsely and as to the meaning of their own person which
Fig. 43. Imbecile, somewhat microcephalic. He could repeat whole sermons

after once hearing theni. Despite the strong vivacity and the many folds the
facial expression is very simple, and coarse.
they easily overestimate. On the other hand,

it is not correct to say
that there are oligophrenics who have not yet separated their per-
sonality from others; if they speak of themselves in the third person,
it is due, like in children, to quite different reasons.
The Affectivity varies extremely; eveiything that occurs in non-
oligophrenics can also be found here. But in these aberrations from
the type there are deviations from the average as well as extremes.
There was a preference for classifying oligophrenics into dull (apa-
thetic), and excited (erethic) types, the former of which are supposed
to be in the majority. But there are just as many transitional forms.
The two types only represent those who on account of their emotional
abnormity attract more attention and hence are more observed. To
be sure, the affectivity easily gives the impression of being more
erethic than it is, because of the slight control exerted through the
intelligence. The lability, which is not rare and which impresses
upon some oligophrenics a childish character, may be due to many
causes. Most of the etiological forms show a preference for a definite
affective state. Thus the cretins
without complications, all move
about clumsily but are jolly peo-
ple; most of the microcephalics
are lively and easily excitable
in all directions; those who
have cerebral lesions are dis-
posed to irritability and endog-
enous moods, etc.
It is self-evident that the
oligophrenics are incapable of
gradating their finer feelings, for
the latter represent reactions to
finer modulations of complicated
ideas which the patients lack.
The facial expression is therefore
undeveloped, just as in a clumsy
looking drawing, but an addi-
tional factor in most cases is the
Fig. 44. Imbecile showing foohsh inadequate motor coordination.
laughter. Although he expresses a cer- Even the tone of speech expresses
tain amount of astonishment or expec-
tation besides the effect of laughter, the
modulations of affects only in
expression is uncommonly coarse and coarse outlines. In some, not
uninhibited. It does not express any exclusively torpid oligophrenics,
pla> ot thought. The expression is the
opposite ot "spiritualized," it is the
there is a marked insensibility to
punch ot figure type. pain, which as a rule may be of
central origin.
Very frequently, especially in actual brain diseases, one observes
depressive or irritable, seldom euphoric moods, which often cannot
be distinguished from those of epilepsy; sometimes they are accom-
panied by headaches and other paresthesias and even by lighter con-
fusions. Moods resulting from outer causes are just as frequent.
Some come to the physician on account of attacks of rage, which in
part are comprehensible reactions to a situation not understood, but
in part represent exaggerated answers to a usual stimulus.
Corresponding to the affcctivity the attention is very varied; to be

sure, it is most frequently normal. Many severe cases impress one
with a strong hypervigility which makes them incapable of resisting
the shghtest distraction; every noise, every fiy coming into their
field of vision distracts them. It is conceivable that education as
well as useful occupation are deeply hurt by it. In some the attention
flags very quickly.
Just as in all aberration, there are marked inequalities in the dis-
position of the various
feelings of the same pa- rr"
tient. But it cannot be
said that definite classes of
feelings are especially lack-
ing or developed. The
moral feelings compara-
tively seldom suffer if oli-
gophrenics who do not come

to the attention of doctors
are also included here;
these feelings naturally
cannot accentuate any of
the more complicated con-
cepts because the patients
are unable to form the
same. Attachments and
love, even gratitude, are
quite commonly seen, al-
though they are markedly
reduced as a result of a lack
in oversight. It is also self-
evident that, all things be-
ing equal, a low intelligence Fig. 45. A 45 3'ear? pyrgocephalus
can only insufficiently con- (steeple-shaped skull) an erethic female idiot,
without clear speech but who can, however,
trol impulses and affective attend to her own wants.
fluctuations. Cretins are as
a rule quiet and kindly disposed, but not really apathetic. With the
majority of oligophrenics one has a vers^ pleasant emotional relation,
just like parents with children.
Sexual feelings and impulses are usually present. A great many
of the patients masturbate. A complete absence of the sexual feelings
mostly occurs in cretinism, but here it is not rare.
The memory in oligophrenics, like the affectivity, fluctuates from
very bad to phenomenally good, but the majority are by far in the
middle zone. It is not correct to say that as a class these patients
have a bad memory. On the other hand, it is quite obvious that things
which they do not understand, and differentiations which they cannot
grasp, are badly retained in the head
exactly like in other people.
Nevertheless just among imbeciles there are striking exceptions;
some remember well things which they do not understand, and some
after one hearing, retain in memory a whole sermon verbally and
Fig. 46. Microcephalic middle grade.
with good imitation of accentuation. Like in non-idiots, a particularly

good memorv^ for numbers, optical impressions, and similar things is
readily connected with special talents in corresponding directions.^^^
Following moods, confusional attacks, and even after strong ex-
citements, perfect or partial amnesias are not rare.
Of the psychic accessory symptoms only the actual excitements
"' For the explanation
of the apparent memory weakness as a result of
insufficient use of experiences, see under association of ideas.
and moods are to be mentioned. But then there are complications,

which in any case are often directly connected with the disease. Thus
above all there is epilepsy, then all possible psychopathies and neuro-
pathies, especially hysteroid manifestations; furthermore, there are
katathymic delusions which may resemble an unintelligent paranoia
but often connected with hallucinations, and under certain fonditions
can be cured. Whether the
schizophrenia sometimes also
observed is only accidental,
having been grafted on oligo-
phrenia, is not yet known.
Physical Symptoms. The
deeper the oligophrenia the
more frequent and the more
pronounced are the physical
anomalies encountered idiots ;
are only exceptionally well

formed people. A part of
the disease is directly con-
nected with the disease of
the brain such as micro-,
hydro- or macrocephalus. As
a result of cerebral and spi-
nal cord diseases the limbs
are malformed and para-
lyzed. Other symptoms are
the accompanying manifes-
tations of the brain dis-
ease.^^ Still others are Fig. 47. High grade microcephalic. 25
loosely connected with the j'ears old, the head circumference
greatest
40 cm. Height 150 cm. In an idiot asylum
mental disturbances and are he was anxious, irritable, uncleanly, crying,
signs of the bad foundation biting, and scratching. Subjected to better
in general; among those can treatment he was a clean, erethic idiot. He
understands requests and can express simple
be mentioned pyrgo-, and ideas in sentences, also slightlj- useful in the
scaphocephalus, all possible house.
"stigmata of degeneration,"
smallness from the beginning of youth ranging up to dwarfishness,
malformed and poorly developed teeth, deep horizontal fold in the
forehead, chronic skin diseases, etc. A
great many dystrophies are
associated with abnormal functions of the endocrine glands, of which
the thyroid, hypo- and epiphysis are especially important. ^Nlany of
"* See pp. 367-8 for the cretin habitus and the signs of congenital syphilis.
these patients not only remain small, but resemble children even in
their general physical formation. The ages of elderly idiots are mostly
guessed as much too young; "they do not age."
The movements are badly coordi-
nated in the severe cases. Speech be-
comes unwieldy, frequently there is
stammering and lisping, rarely stutter-
ing. The distinctions between primary
and secondary syllables are often in-
sufficiently accented, and the soft
palate closes badly (nasal sound).
The perception and imitation of the
refinements of speech in its various
directions may especially be disturbed.
The gait of idiots, if at all possible,
isawkward, and clumsy; the patients
have not learned to use only the
necessary muscles in quiet attitudes;
they waddle and walk too heavily;
elasticity and grace are absent. Where
the labyrinth is deformed one observes
the characteristic disturbances. Not

rarely there is a finer or even coarser
tremor sometimes during motion, and
sometimes even at rest.
The knee reflexes are almost al-
ways exaggerated.
The Behavior. The most severe
cases of idiocy are perfectly helpless.
They lie or sit around like children;
they are regularly unclean. Depend-
ing on the temperament, they play or
are unruly, they are noisy, strike one
another, or anything at all in the
FiG. 48. Cerebral infantile
paralysis, showing the tj'pical at- surrounding. Many of them, and still
titude of the right upper extrem- fewer of the higher grade idiots, have
ity. Slight atrophy of the right
definite movements; they rock them-
leg.
selves, shake their heads, and make
definite playful motions with their fingers, etc. These movements are
frequently accompanied by definite grunting, crying, and grumbling
sounds. Erethic idiots who cannot be educated are a great plague,
especially if they are still capable of going about. They grasp every-
thing, they soil and destroy things througli carelessness and also
intentionally.
Those standing on a higher level lack "bearing"; the hanging jaw.
the open, sometimes gaping mouth, frequently evince a lack of psychic
energy.
Even those who are fortunately not so often erethic and approach
to the middle level of imbecility are not so easy to manage, because
they forever harbor some design; intentionally or unintentionally, they
are up to something, they run away, steal, and fight. Sexual crimes,
exhibitionism, murderous attacks up to lust murders, are not so rare.
The more quiet ones, if they can keep themselves clean and eat alone,
can be managed like children.
The sex character shows itself in all of the various classes in a
remarkable and pronounced manner. Feminine idiots wish to have
attention and invent for this purpose every possible trick they scratch;
themselves, so that the physician should have to treat them, etc.;

even the best of friends are jealous of one another. It frequently
happened that I had to pull out teeth simply because I performed
this operation on one of the fellow inmates. Male idiots tease and fight
readily, even though there is no enmity between them.
At play as at work many of them continually become more and
more stimulated until they can no longer stop and finally merge into
excitement like some children.
In so far as they are not hindered by criminal tendencies, imbe-
ciles of higher standing with an orderly bringing up fit in the family
and social order, and most of them can make themselves somewhat
useful; in cases of special talents or in other good conditions the}'
can even earn nice sums. One of my patients did verj- well as a
"landscape painter" at a watering place by manufacturing always
the same picture cards in great numbers.
Many imbeciles feel the need to show that they are not so stupid;
that is, they have a strong "intelligence complex" which results
not only from the inadequate self-cognition but directly from the
feeling of insufficiency for which they compensate. To be sure, the
intelligence complex, be as an overestimation or as an idea of
it
insufficiency, is also found in other patients and in healthy people.

Crimes are not seldom committed by imbeciles, and that not only
by those brought up with difficulty and by moral defectives, but also
by those who are otherwise kindly disposed; in their faulty valuation
of things, slight occasions may often lead to murder and especially
arson. (We have already spoken of sexual crimes.) A slight quarrel
with the employer may provoke a suicide^ a simple reproach for some-
thing wrong, an act of arson. An imbecile was displeased because his
brother and sister-in-law were talking nearby, so he set fire to the
house. How a lack of judgment and comprehension of the situation
may lead to a violent act was shown by a mental weakling who has
maintained himself independently for years. He went to a comrade
Fig. 49.Female idiot with an enormously undeveloped muscular system; the

skin was tightly stretched so that e.e. there was no longer any conj\mctival sac.
Height about 120 cm. She looked no different in life than she looks here as a
corpse. She never attained the weight of 120 kilos. She could make herself
shghtly understood through speech. Imbecilic excitements on emotional bases.
Was able to knit. Died at about the age of 40 jêars. Her twin sister is exactly
the same.
who had an account in a delicatessen store and warted to buy a

sausage and bread on the former's account. The comrade naturally
hesitated, whereupon the patient created a row and, as he was threat-
ened with the police, he walked out and broke a show window. Mental
weaklings naturally ver>' readily imagine themselves in an untenable
situation and may then commit the crimes described above.-^^
^ See p. 538.
Course. Deeper congenital idiocies are mostly recognized very

early. The children fix on nothing, do not grasp after objects, do not
laugh, and remain backward in everything that is called psychic, and
mostly also physical development. To be sure, in some cases the oligo-
phrenia first starts after birth in consequences of a brain disease, espe-
cially encephalitis and meningitis. Many lighter forms fail for the first
time at school, still others when they are about to apply the material
learned in their apprenticeship, or even later on going out into inde-
pendent existence, or in the army, where they attract attention not
only through ignorance, but also through stupor, and desertion.
Women easily become prosti-
tutes, men alcoholics; both fre-
quently get on the streets. A
sudden event like the death of
the parents, which puts the pa-
tients on their own feet, some-
times brings the disease to the
surface; likewise other new
tasks, a change of place with new
relationships, may bring on a
stupor, or anxiety rising to con-
fusion with delusional ideas, and
even hallucinations.
The marked diversity of the
quantitative course depends on
the disease lying at its founda-
tion. Some are backward only
in comparison to other children,
Fig. 50. An idiot playing with her
fingers. She is grown up but cannot
but continue to catch up to some talk. Somewhat stupefied features in the
extent. Others continually be- presence of the act of being photo-
graphed.
come worse, especially at pu-
berty, regardless of the other standard which results from the new
tasks. Among these "progressive oligophrenics" one especially finds
hereditary lues. Sudden or gradual aggravations may appear even
later, the cause of which is not known; in any case there are slowly
progressing cerebral degenerations of various kinds. The vital force

of oligophrenics, especially of idiots, is poor. On the average they do
not get old. They easily become have seen them as early
ill I as in
their fifth decade with pronounced brain atrophy.
The causes of oligophrenia can be divided into the following
classes:
I. In one class it is a matter of various faDiUij predispositions,
which manifest themselves in this way ; it is said that oligophrenia is
the last link of a progressive degeneration. This concept is not clear

and not proven.
II. There are also germ injuries through alcoholism of the parents
(procreation while drunk?), syphilis, and still other diseases.
General diseases of the mother and her pelvic organs may
III.
under certain conditions, even though quite rarely, bring about a
malformation of the skull and the brain.
IV. Brain- and general diseases of the fuctus and the child, above
all meningitis and encephalitis, as well as any brain injury.
''
''^^^--'^H^^^^^^^^^^^^K
^^^T^.*.^
^ '^^^^r-^
^^^^^^r
^^K-^^B
Fig. 51.
1
Half sided microgyria in a mild imbecile with hemiparesis.
The names (taken from Weygand) may give an idea of the special
diseases:
1. Psychic defective states in early youth due to lack of education.
2. Psychic defective states due to an absence of some of the senses.
3. Psychic weakness due to an inhibition of disposition.
4. Idiocy on the basis of inflammator}^ brain diseases.
5. Idiocy on the basis of inflammation of the meninges.
6. Idiocy through hydrocephalus.
7. Amaurotic familiar idiocy and related disturbances.
8. Tubercular hypertrophic sclerosis.
9. Mongolianism.
10. Infantilism:
Infantilism due to heart disease.
Infantilism in intoxications and infectious diseases.
11-16. Glandular infantilism.

11. Status thymico-lymphaticus and idiotia thymica.
12. Thyroid disturbances (Dystliyroidismj.
13. Dysgenitalism.
14. Hypophysis disturbances (Dyspituarism) acromegaly.
: Dys-
trophia adiposo-genitalis.Hypophysary dwarfishness. Epi-
physary disturbances.
15. Adrenal disturbances.
16. Pluriglandular diseases.
17. Syphilidogcnic idiocy and infantilism.
18. Alcohol and weakmindedness in childhood.
19. Athetoid Idiocy.
20. Chorea and weakmindedness.
21. Spasmophilia and epilepsy.
22. Idiocy and rickets.
23. Chondro-dystrophia and weakmindedness.
24. Steeple shaped skull and weakmindedness.
25. Dementia prsecox in childhood.
26. Dementia infantilis.
27. Manic depressive insanity in childhood.
28. Hysterical degeneration and inhibitions of development.
29. Neurasthenia and infantile inhibitions of development.
30. Other diseases of the central nervous system in connection
with psychic inhibitions of development.
Many of the forms concern more boys than girls.
Special Forms. Still two more states of idiocy are described, which
do not altogether fit in with our cases of oligophrenia and should better
be put under the original morbid states or under the psychopathic
personalities.
I. The Uncleai" Ones.There are cases which are not at all so poor
in associations, andform unclear concepts. They have not as
still
yet been particularly described. The unclearness seems to be con-

nected with a lack of firmness in the association complexes, so that a
concept, or an idea has at this moment this limitation and in the
following moment quite another, without the patient being aware of it.
Most of these cases are active natures, who are related to the manic
temperament. They have a great many phantasies and
are quite
unsteady in their desires and actions.--^
Illustration: Carpenter builder, owner of his own business. "He
rarely answers a question clearly and directly, even where it would
be to his advantage and where there is no reason for evading it. He
*^
Cf. pp. 26, 68, 68.
usually says something else from which one must figure out the answer.
He designated it as a libel on the part of X. when the latter, as a
witness, confirmed the fact that the patient smoked at his work,
which he admitted himself. This indistinctness is one of the reasons
for his absolute inability to judge himself and to realize his faults.
After I have, for example, recounted to him all his rude actions towards
his wife and he admitted them in part, he could still say that he was
a good husband, that one like him she will never get. As a matter
of fact, just as in the former asylum he is even still now 'pretentious'
and pleased with himself."
When he came to the hospital he believed that he had Fr. 25,000
in cash, while his wife had to exert the greatest effort to save the
business from bankruptcy. He believed that it would be easy to put
the business in a flourishing state, but could not say how. And then
he again spoke in the same sense and wished to make us believe that
he conducted the business better than his wife. To be sure, he had
once himself confirmed the fact that his guardian had saved his
houses for him.
He know whether his machinery was mortgaged. He
did not even
did notknow how much he owed on his property. He signed notes
and had no idea how he would pay them. He made a direct demand
that his wife pay him back Fr. 25,000 but could not substantiate it.
On what grounds he would base his claim when he would sue

legal
his wife for the return of his business he had no idea. Once he went
so far as to assert that there was no need of getting the business
because the business was His foolishness in allowing himself
his.
to be sued by the Woman's Clinic for a small sum, he does not even
realize now. As he was angry because his wife went to the clinic he
refused to pay, but failed to understand the consequences, namely,
that in so doing he did not hurt his wife, but the innocent clinic and
above all himself. So also when he incited the workingmen against
his own business merely to cause his wife difficulties. Just as foolish
was his action in the hospital when he refused to give a history of
his life, or to object to his temperature being taken when he was
sick. And the worst of it is the fact that even now after four
years he is not able to recognize the mistakes he then made in
anger.^^^
The lighter grades of this and similar disturbances are designated
since Von Guden as higher dementia, according to Hoche as "parlor
dementia." It concerns people who usually absorb the school material
quite well, under certain conditions even excellently, and can even use
"" Cf. also the Nature Healer, 69 and below.
p.

it in certain combinations, but in spite of great activity they are

failures in life. Their behavior is the reverse of the oligophrenics;
they have much knowledge and can do nothing. Endowed with a
good, even not with a very exact memory, and with a more or less
if
readiness of speech, they fool many a teacher; indeed, they may pass
their college examination and even higher ones. Above all, they
have a great adapt themselves quickly to circumstances
ability to
but only externally. In certain relations they are instinctive psy-
chologists and thus very able to "do" the people. One finds among
themome very successful swindlers. If their oral and printed psychic
products are more closely observed, one finds repetitions of ideas of
others in newer arrangements and more confused formations of the
same. A young man had gone so far in another college that he became
a lecturer; when he had to examine officially a girl who was illegiti-
mately pregnant he could not understand how this was possible; he

took an umbilical cord for -a fcetal ventral fin. Another held political
speeches, but among other things he was rigid and firm in believing
that the only aim of the other party was "to make the people stupid."
A third was a nature healer; he wrote a mass of pamphlets, had an
enormous income and maintained so many disciples that they formed
many sections of a society, which existed for years, to spread his
truths. This patient wrote the following, among other things:
"Transparency with the help of self-cognition and world cognition
can only be produced in so far as the person is transformed into a
love glowing condition." He wanted man to become transparent so
that his diseases could be seen. "In the glow, bodies if they don't
become transparent they are at least translucent, hence also in the
glow of love." Such is the unclearness of the concepts and logic of
such people.
II. Another form into which the higher dementia merges without
any demarkation is the relative dementia. Not always, although

frequently, there exists also here a certain unclearness of thinking.
The most however, is a disproportion between striving and
essential,
understanding. There are people whose understanding suffices for a
usual attitude of life, and often even for one a little above the average,
who, however, are too active, and constantly adjudge to themselves
more than they can grasp, and therefore commit many stupidities and
suffer shipwreck in life.--^
The psychic ^^* diagnosis of idiocy is self-evident; of most cases
-^ Bleuler, Verhaltnisblodsinn. Allgem. Zeitschr. f. Psychiatrie ii. Psj-chisch-
gerichtliche Medizin. Bd. 71. Reimer, Berhn, 1914.
^ The diagnosi$ at the basis of the brain disease is here omitted.
of imbecility it is also easy it first becomes difficult in the lesser pro-
;
nounced forms and in cases of mental debility.

However, high grade cases have also been confused with schizo-
phrenia. Disregarding the combination of both diseases (grafted-
schizophrenia) one must consider the kathathymic delusional format
tions of oligophrenics, which can only be diagnosed from grafted para-
noia by the absence of definite schizophrenic signs, and by the fact that
it may disappear altogether.
The stereotyped formof movements of many idiots cannot really
be mistaken for the stereotyped movements of catatonics, if one has
seen both forms. They have the character, if not of a deliberate,
yet of a willed act like the dangling of a leg; they do not give the
impression as if they ran side by side with consciousness and contently
are also easier understood and more elementary. The answers to the
usual questions concerning birth, what he didwhen examined in school,
what he was doing now, what his father was doing, frequently betray
the defects by the slowness and unclearness of the understanding and
by the circumstantiality of the answers.
The stammering and other speech disturbances of the imbeciles are
not seldom mistaken for paretic speech. The elisions of the latter,
the stumbling of syllables, and the addition of these signs in certain
coordinating difficulties are nevertheless still easy to recognize. In
contrast to this one rarely observes in the oligophrenics an inability to
get away from the individual sounds; more often there is a gliding
over, a swallowing of the sounds; moreover, the organic connection of
the successive sounds is often absent; it is as if they begin to learn
a foreign language.
Only can be psychically diagnosed in early childhood;
idiots
children who do notlaugh, who do not grasp for shiny objects and
in general react insufficiently are idiots. Severe cases of malformations
of the head frequently enable even the layman to recognize the
disease.
As acquired dementias may in some relations externally injure
the actual thinking in a manner similar to those of oligophrenics,
one of the most important diagnostic means is the proof of the insuf-
ficient acquisition of ideas and knowledge in youth. By assuming a
definite schooling and a full receptive capacity through the senses,
it is then possible to draw conclusions from the existing knowledge
concerning the intelligence at the time ofits acquisition, that is, one
can find out to what degree of complexity material has been received
during school time, to what degree it was understood and could be
elaborated upon. But it should not be forgotten, as often happens,
THE INDIVIDUAL MENTAL JJLSEA8E8 619
that the knowledge test is not the intelligence test but the material
for it. A schizophrenic, an organic patient, or epileptic who is still
in the stages when an examination can still be made will not lose the
more complex and markedly abstract concepts which he has formerly
acquired. The lack of such acquisition can thus demonstrate oligo-
phrenia. But one must be experienced to know what to expect in this
direction in the various circles of average people, and especially must
it not be forgotten that a person may be above the average in one
sphere and at the same time below the average in another.
In both cases one must consider the interest, and the attention
applied to the learning. One can remain back at school not only on
account of insufficient intelligence, but also when one does not pay
attention, or does not exert himself. In the same low intelligence
one who has the need in life to follow up the causal relations can know
more than another who is indifferent in this relation.
Moreover the patient may suffer from an examination stupor, he
may not be at home in a special sphere, he may be somewhat nega-
tivistic, or, as often happens at examination, he may have the bad
will to make himself appear stupid, and finally he may on the contrary
pass excellently all such tests and fail completely in the one standard
examination which goes throughout life. The latter may be due to
the following variety of causes: his weakness may lie more in the
sphere of the affectivity or of the will, or he may have little under-
standing for just practical ideas, or his impulses may give him prob-
lems and lead him into situations for which even a good intelligence is
not big enough. Similar situations are frequently observed in schizo-
phrenia, where under certain conditions the patient will be able to
do cube root with ease, and fully understand the whole procedure, but
is incapable of dressing himself properly.
The cases of mental debility and the poorly endowed healthy per-
son are distinguished from each other not by the amount of their
knowledge but by the measure of their ability, by the ability to use
theirknowledge independently. It is not a question of intelligence
as such but of intelligence as a guide through life. And only in the
latter direction is the mental weakling necessarily defective.--^
The decisive factor in all difficult cases is therefore the anamnesis
which must be taken here with particular care.
In the deeper standing imbeciles the Bind tests (p. 596) are quit-e
useful for some purposes. One can also request the patient to finish
incomplete sentences, fill in Ebbinghause's unfinished text, explain
^ Wagner von Jauregg, Gutachten. Wien, Klin. Wochenschrift, 1913, 26, p.
1947.
620 TEXTBOOK- OF PSYCHIATRY
pictures, interpret proverbs, and repeat and explain fables.^^^ Such
tests are only useful when circumstances are taken into considera-
all
tion; and as it is precisely the beginner who is sure to lack the perspec-
tive of all mattersthat come into consideration, one is explicitly
warned against the careless application oj the tests. Moreover the
manner of answering is much more important than the content. The
test examinations furnish very good occasions for the state of intelli-
gence to reveal itself under conditions, but it does not necessarily do so.
In all lighter cases, however, all these things are of secondary im-
portance. All the theoretical tests can be passed faultlessly, while the
patient is perfectly unfit to manage his own affairs. It is not a ques-
tion to test theoretically and actually his understanding of his own
business, but above all his whole past, in order to see how he behaved
himself here. Life is really the only sure touchstone.
What is here said concerning theoretic examinations should only
be considered as illustrations and suggestions for individual procedures.
It is impossible to prescribe all that is to be examined in the individual
case. It is not always of special importance what one talks with the
patients, but how one observes and how one concludes. Here as in
no other place the physician mu^t set aside his own reason, and de-
pending on the condition of the case he must omit some tests and
insert others. The most important thing is always the judgment of
the observations and inquiries. Despite all rules the intelligence test
is as much a test of the doctor's intelligence as of the patient's
intelligence.
But all that was said here refers only to the original state of in-
telligence; to use the "intelligence test," by which it is customary to
understand only a rapid examination of school knowledge and at most
also the knowledge of life, in cases of acquired forms of dementia,
especially with the object of excluding a dementia praecox, is absurd;
to try to make a diagnosis through it is impractical.
Procedure of the Intelligence Tests. The first thing to do in making
an intelligence test is to try to get in contact with the patient so that
he should not merge into an examination stupor or fall into a negative
attitude; one therefore attaches the conversation to something quite
natural, perhaps by questioning him about his health, his sleep, or his
situation. And according to the patient's reaction a subject is chosen
which he is most likely to take up. The differences between the sexcG
are also to be noted; on the whole, more practical and psychological
knowledge is expected in women than theoretic and exact knowledge.
For further detail see Ziehen, Die Geisteskrankheiten des Kindesalters.
^^''
Reuter & Reichard, Berlin, 1915.

THE INDIVIDUAL MENTAL DISEASES G21
Too much cannot be expected of them in concepts relating to

geography and geometry.
One tell about his family, what
allows the patient, for example, to
the father does, and similar things. One can then enter into his school
knowledge by asking him how he was at school, what subjects he liked
best, etc. In this way it can be ascertained whether he was left back.
When he relates something from history, it is not most important to see
how much he knows, but how he elaborates it, especially whether he
recounts details in phrases which he has perhaps learned by heart, or
betrays a review of things gained through independent grasp and
judgment, or whether he repeats something that is of current opinion,
etc. Just here often possible to find out to what extent the pa-
it is
tient was able work out the essentials and whether he has a sharp
to
grasp of things or not. One also notices whether he relates things
diffusely or whether he is able to condense them. To hang on the non-
essential, on the perceptible, and in connection with the other symptoms
also to omit the logical intermediate connections without noticing it
shows imbecility. Especially suitable for differentiating between

phrase-like repetitions and fully understood elaborations are ques-
tions from biblical history and from the simpler dogmatic theology
("Why did Christ die?"). In geography it is characteristic of many
oligophrenics that they are well oriented as to their environment in
so far as they have learned it through experience, but become unclear
or do not know as soon as they are asked something that they should
have learned from theory. Even elementary knowledge in cosmic geog-
raphy such as how day and night come about, or darkness, etc., need
not be expected with certainty from every healthy person nevertheless ;
even here the answers are characterized by good understanding on the

one hand, and the opposite in the case of oligophrenics. In calculat-
ing one frequently finds that in practical life they have the capacity
to get through with current buying and selling examples and card play-
ing while they fail in simple theoretical examples. Rarely is the case
reversed, in that the patients repeat only what was taught in school
and reproduce it manner they studied it, but cannot apply
in the
it to practical life. The latter patients seem at first the more intelli-
gent but they are more helpless in life. In testing in mathematics,
like in everything else, one should begin with easy examples and pro-
ceed to the more difficult (first ask patient to count coins, addition
and subtraction, then multiplication. The tables are usually a mat-
ter of memory and not of understanding. There are imbeciles who
cannot solve 2 + 2, but can easily solve, for instance, and 2X2
14 X 14. Then go to division and finally to fractions).
The patient is then allowed to read something simple, e.g. one of
the fables from p. 189. Oligophrenics are in most cases easily differen-
tiated from later acquired psychoses by the schoolboy's way of read-
ing, by the difficulties in rarer or more complicated words, etc. The
reproduction of the content is not so easily judged because disturb-
ances of attention easily play a part hereeven a normal person, when
;
excited,can read whole pages without grasping anything.

In most cases one can quickly orient himself to an extent that he
can save himself the questions which are too easy or too hard for the
special case. But in order to obtain as far as possible an exact meas-
urement of the height and the manner of the understanding, it is
necessary among other things to put questions which also seem some-
what difficult. The latter often causes people to say that we ask the
patients things which even a healthy person cannot answer, and that
we incorrectly diagnose mental weakness from this sort of not know-
ing. Regardless of the necessity for restriction, such questions should
nevertheless not be avoided, because it is not only a question of know-
ing and not knowing but of how the patient answers. Does he not
realize himself that he does not understand the thing? How does he
conceal his ignorance? How does he help himself out of difficulties?
Such observations rather than direct questions enable one to recog-
nize easier the psychic height of the not severe cases of imbecility, and
it is particularly the unclear cases which can be discovered best in this
manner. What one asks is indeed really not so important as what

one concludes.
Already from the oral examination it is possible to write a life
history from which one obtains without anything further the degree
of school education, also the conception of life, the wealth of the asso-
ciation of ideas, and many other The mode of writing with
things.
its awkwardness in letter formation and grammar and content is often
characteristic of oligophrenia. The patient is then allowed to see

simple pictures, and one observes whether he differentiates between
current things and those occurring more rarely, which one knew only
from description, such as strange animals, plants, etc.
Then one uses pictures which represent a situation and observes
whether the patient grasped only the detail or the whole meaning.
If, as exceptionally happens, the examination has thus far failed
to display the patient's capacity for abstraction, i.e. if it has not been
discovered to what extent the patient is able to form abstract concepts
and use them, an attempt should be made to talk to him directly about
abstracts (work, sleep, jump, memory, glance, poverty, joy, beauty,
bravery, state, redemption), but great care must be exercised in doing
it. Even healthy persons are not able to define easily the common
definition.
One can then start a conversation about things of life. How does
he judge his relationship, eventually his crime? Does he know from
where the material comes for his own trade? Does he know the
significance of the individual manipulation? etc. Why did he run
here and there from his work? What does he intend to do? How
does he wish to get out of this muddle?
Very good starting points, indeed often the diagnosis, can be
obtained through the association experiment.
One must guard in everything against taking glibness of tongue or
ape-like reproduction for knowledge or even understanding; moreover
one must watch for clearness of ideas especially in people who are
endowed with a fluency of speech.^^^ If the patient has no stupor
one must verify the degree and extent of his attention, fatigue, etc.
Furthermore, the affectivity must be accurately observed; one should
also see in how far it controls the logic. For this purpose it will some-
times be necessary to bring up at the end of the examination, when
there is nothing more to spoil, emotionally accentuated themes, such
as hurling at the patient merited reproaches, etc.
The second, often more important, part consists in ascertaining his
behavior at work and leisure, during the observation, and in his past
life.
The actual oligophrenias are very frequent diseases; more than one
per 1000 of the population belongs tothem. Nevertheless the
physician has really very little to do with them.
Treatment.^^^The unclear types and the relative dementias do
not come so often to the physician. They are all incurable, but here
and there still somewhat educable; but more than taking measures
of guardianship can hardly be applied to them with any success. Early
intervention by transferring the patient into an environment which
will take account of his peculiarities and consequently keep him away
.from all wrong waj^s may produce a certain improvement.
Against the disease itself up till now only in cretinism (Thyreodin)
can something be done, perhaps also in congenital syphilis.
Otherwise it is simply a question of care arid education. Both
must be understood in a special way. A certain amount of adapt-
ability is possessed by almost all patients even also by the severer
idiots. In consequence of unfavorable treatment, especialh' in cases
""Compare the example of uncleamess, p. 615.

^^Cf. also: Th. Heller, Piidagogische Therapie fur Arzte usw. Leipzig u.
Wien, 1914.
of beating or coddling, some patient may become a dangerous and
harmful individual, the control of whom will necessitate many people,
but who under proper treatment may act like a lovely child. Where
dangerous tendencies exist commitment is naturally necessary. Of
special importance in the lighter cases is the selection of the right
vocation, which should better make too little, than too many demands
on the abilities and energy of the patients. Many parents wish to
go too high.
Also in later life it is especially important that the patients have
a position in life suitable to their abilities and temperament; too high
demands are always harmful. But even in the cases who are seem-
ingly most hopeless one should not forget that in most cases some
improvement is possible, very often much improvement, if the patient
is put into the right hands. Some of the educational institutions for
oligophrenics are very useful.
In excited cases of hydrocephalus a lumbar puncture or even a
puncture of the ventricle may give temporary alleviation. The first
operation can even be periodically repeated.
Where there is a tendency to sexual excesses, sterilization or castra-
tion may take the place of permanently confining the patient. But
one must govern himself regarding this advice according to the views
of the environment and follow the legal forms, such as the consent of
all concerned, the guardian, or counsel ad hoc, etc.
Finis
INDEX
Aoasia, 543. Alcoholic paresis, 350.
Abdcrhalb, rnaction, 442, Alcoholic p.seudo-paresis, 350.
Abortion, 222, 445. Alcoholic psycho.ses, 299.
Abreaction, 38, 39, 501. organic, 345.
Absences, 448. Alcoholic twilight state, 302.
Abstraction, 16. Alcoholism, acute, see Intoxication.
Abulia, 51, 143. Alcoholism, chronic, 303.
Accessory symptoms, 54. Algolagnia, active and pas.sive, 574.
Accident neurosis, 564. Alternating personality, 137.
Activity, disturbances of, 141. Altruism, see ethics.
Acute confusion, 364. Alzheimer's disease, 296.
Acute course, 167. Amaurotic idiocy, 182, 243.
Acute dementia, 365; curable, 365. Ambitendency, 382.
Ambivalencv, affective, 125, 130; schizo-
Acute (hallucinatory) paranoia, 164,
487. phrenic, 382.
Affect reaction, see Affective result. Amentia, 163, 193, 364.
Affect stupor, see emotional stupor. Amnesias, 100; anterograde, 102; retro-
Affective actions, 149. grade, 102.
Affective effect, one-sidedness, 126; Amuck, 459.
morbidity of, 493. Amylene hydrate, in enemas, 223, 276.
Affective effects, exaggeration of, 494. Analgesia, 56.

Affective epilepsy, 459. Androgynous, 577, f.n.
Affective perversions, 126. Anesthesia, 57.
Affective psychosis, 465. Anonvmous letter writers, 539.
Affective exaggeration of, 126.
result, Anxiety, US, 119.
Affects, abnormal duration of, 124. Anxiety deliria, 211.
Affects, affectivity, 12, 32. Anxiety neuroses, 165.
Affects, deficiency of, 126. Anxiety psychoses, 165.
Affects, displacement of, 35, 37, 118, 499. Anxious mania, 478.
distractibility of, 124. Apathetic oligophrenia, 605.
disturbances of, 117. Apathy, 124.
dominating forces of, 33. Apoplectic cerebral lues, 248.
examination of, 188. Apoplectic insanity, 281.
Apperception, 13; disturbances of. 57.
lability of, 124.
occurrence, 197. Appersonation, 137.
Agitated dementia, 436. Apraxia, 146.
Agitated depression, 478. Aprosexia, 134.
Agitation, constitutional, 485. Arithmomania, 561.
Agoraphobia, 561. Arterio sclerotic insanity, 276, 277.
Aichmophobia, 561. Artificial feeding, 221.
Aim of thought, 21. Artificial language. 398.
Akinesia algera, 542. Association, 12. 17; brevity of, SI. So.
Akinesis, 146. Association disturbance, 71 occurrence ;
Alcohol, as therapeutic agent, 223, 326, in, 195.

341. Association experiment. 41.
in brain traumas, 241. Association hostility. 42.
Alcohol delirium, chronic, 346. Association, laws of, 41.
Alcohol epilepsy, 353. Association mediate in schizophrenia,
Alcoholic delusions, 351. 376.
hallucinosis, 163, 341. Association readiness, 41 in delusions
Alcoholic ;
Alcoholic intolerance, 301. of reference. 95.

Association reflexes, 23. 494. 49S; in
Alcoholic melancholia, 354.
Alcoholic paranoia, 351. hysteria, 554.
625
626 INDEX
Association tests, 188. Causal thinking, 20.
Associations in oligophrenia, 82, 597, Cause, concept, 19, 20.
et seq. Causes of mental diseases, 200.
Astasia-abasia, 543. Centrifugal functions, disturbances of,
Athetoid movements, 157. 142.
Attacks, 166. Centripetal functions, disturbances, 55.
catatonic, 400. Cerebral concussion, 241.
epileptic, 445, et seq. Cerebral inflammation, 242.
hysteric, 547. Cerebro-spinal fluid, 238; in cerebral
paretic, 254. lues and luetic pseudo-paresis,
Attention, 4. 247, 248 in paresis, 254.
;
Attention, blocking of, 135. Character, 39, 128.

disturbance of, 133. Child paresis, 250, 270.
Attitude, false, 127. Child psychoses, 212.
Attonity, 146, 163, 411. Childbirths in mental diseases, 159; as
Auditory muteness, 604. causes of, see puerperium.
Aura, 446. Childhood, disposition to psychoses,
Autochthonous ideas, 91, f.n. 212.
Automatism, automatic actions, 8, 150, Chloral, 222.
152. Chloralamid (in enemas) 276.
in schizophrenia, 408. Chorea, Huntington's, 243.
Autosuggestion, 44. Chorea gravidarum, 363.
Chorea gravis, 363.
Barbed wire disease, 536. Chorea magna, 363.
Basedow's disease, 365. Chorea minor, 363.
Baths, 220. Chorea St. Viti, 363.
Bed treatment, 221. Choreic movements, 157.
Beer-heart, 303. Chronic course, 167.
Belief, 47. Circular dementia, 433.
Beriberi, 207. Circular forms, 168.
Bladder, stuttering of, 127. Circular insanity, 483, see Cyclic in-
Blastophthoria, 203, 559; prophylaxis, sanity.
214. Circumstantiality, 86, 450.
Blood-pressure (arterio-sclerosis), 284. Civil condition, as cause of psychoses,
Bodily weight, 159. 208.
Borderlines of insanity, 170. Civilization as cause of insanity, 207.
Brain diseases, insanity, 242. Classification of mental diseases, 173.
Brain injuries, insanity, 240. Claustrophobia, 561.
Brain tumor, 242. Clavus, 542.
Brevity of the associations, 81, 85. Clear-mindedness, 116.
Bromide, 223; in cerebral traumas, 241. Climacteric psychoses, 211, see Involu-
Bromidia, 279. tion psychoses.
Bromism, 463. Climacterium as cause of insanity, 211.
Buffoonery syndrome, 165; in prison Climacterium virile, 211, 488.
psychoses, 535; in schizophrenia, Climate, causes of psychoses, 207.
412. Climatic treatment, 222.
Burdening of heredity, 200, 203. Clouded states, 162.
Buying maniacs, 540. Cloudiness, 114, 163; in schizophrenia,
Buzzard's method, 186. 412.
Cocaine, following brain injuries, 241.
Cachexia-strumipriva, 366. Cocainisra, 359.
Carbonmonoxide poisoning, 299. Collapse delirium, 364.
Catalepsy, 153. Collecting mania, 586.
Catatonia, 417, 434. Collective unconsciousness, 44.
Catatonia, chronic, 434. Collectors, morbid, 540.
Catatonic states, 412; in fever, 361. Color-hearing, 66.
Catatonic symptoms following traumas, Coma, 56, 114.
199; in child psychoses, 212. Combined psychoses, 193.
Catatonic-like symptoms, occurrence, Command automatism, 152, 154; in
199; in paresis, 256. schizophrenia, 408.
Catatonic symptoms, 148, 154, 199, 403; Command negativism, 407, 408.
in paresis, 256. Commitment, 216.
INDEX 627
Commotion psychoses, acute, 240. Degeneres

Compulsion neurosis (199), 505, 560; superieurs, 164.
Freud's explanation, 89. Delire chronic a evolution ayBtcma-
Compulsive acts, 68, 149, Im-
150, see tique, 437, 529.
pulsive insanity and CompuLsion Delire d'emblee, 91.
neurosis, Delire d'enormite, 93.
affect, 561, 562. Delire de negation, 93.
fears, 561, see Phobias, Delire du toucher, 88.
hallucinations, 563. Delirium, 111, 162.
ideas, 87, see Compulsion neurosis; Delirium, acute, 162, 364, 436.
differentiated from crowding of Delirium, exhaustive, 365, 436.
thoughts, 80. Delirium in schizophrenics, 413.
impulses, 89, 561, et seq. Delirium nocturnal in organics, 234,
laughter, 409. 279.
processes =
compulsive phenomenon Delirium tremens, 326.
in schizophrenia, 408. Delusional insanity, 162; acute (amen-
syndrome, 165. tia), 365.
Concepts, 13; disturbances of, 68. Delusional in.sanity, hallucinatory of
Condensation, 375. dnmkards, 341.
Condition reflexes, see Association re- Delusional insanity, manic, 469.
flpVPg Delusional insanity, melancholic, 476.
Confabulation, 106, 107, 231, 333. Delusional insanity, schizophrenic, 412.
Confusion. 86, 113-114, 162. Delusional need, 90.
acute, 301. Delusional reactions, 495.
delirious in syphilis, 247. Delusions, 90.
flight of ideas, 466. Delusions, recognition of, 187.
hallucinatory, 436. Delusions of being pardoned, presenile,
Consciousness, 2. 536.
disturbance of, 2, 111. Delusions of drunkards, see alcoholism.
double, see person. Delusions of grandeur, 92.
of space, 2. Delusions of injury, presenile, 279, 414.
Constellation, 21, 22. Delusions of jealousy, 94.
Constitutional depression, 484; excite- Delusions of paranoiacs, 521.
ment, 484. Delusions of persecution, paranoid of
Contentious, 591. the hard of hearing, 55, 533.
Contractures, 157. Delusionsof poverty, 93.
Conversion, 501. Delusionsof reference, 94.
Convulsions, 157. Delusions of sin, 92.
Coordination disturbances, 157. Dementia, 164, 365.
Coprolagnia, 574. Dementia, acute, curable, 365.
Coprolalia, 150. Dementia, alcoholico-senilis, 293.
Coprophagia, 149; in schizophrenia, Dementia, dull, 436.
381. Dementia, higher. 616.
Cretinism, 367. Dementia, negativistic. 436.
Criminals, classification, 587, 588; con- Dementia paralvtica, 230, 249, 250.
genital, 591. agitated. 258, 267.
Ciyptomnesia, 109, 110. anatomy, 267.
Curing with defect, 169. catatonic form, 259.
Cyclic forms, 168. causes, 268.
Cyclic insanity. 483. classic, 258, 259.
Cyclothymia, 485. course, 256.
cyclic, 259.
Damage suit litigants, 566. depressive, 258, 263.
Damage suit neurosis, 498, 564. diagnosis of. 236, 236.
Deafness, 55. euphoric, 259.
Debility, 593. expansive. 258, 259.
Decision, 11, 51. foolish. 433.
Decision capacity, disturbances of, 144. galloping, 259.
Decortication, 268. grouping, 257.
Degeneration, 164, 201. infantile, 250, 270.
Degeneration psychoses, 160, 202, 436; Lissauer's, 268.
stigmata of, 160. melancholic, 258, 263.
628 INDEX
Dementia neurasthenic, 259. Drunkard's delusions, see Delirium
paranoid, 259. tremens.
pathology of, 270. Drunkard's misery, 354 f.n.
physical symptoms, 250. Dualisms, 3.
psychic symptoms, 230; accessory,
255. Eccentrics, 587.
simple demented form, 257. Echokinesis, 562.
stuporous, 259. Echolalia, 152.
treatment, 275. Echopraxia, 152; in schizophrenia, 408.
Dementia paranoid, 414, 437. Eclampsia, 299; in children, 459.
Dementia prsecox, 372. Ecstatic pain, 129.
Dementia post-syphilitica, 247. Ectasies, 113, 165; in schizophrenia, 412.
Dementia, schizophrenic, 385. Education, as cause of psychosis, 211;
Dementia, secondary, 169, 372. as prophylaxis, 215.
Dementia senilis, 230, 276, 279, 299. E'go, 49 (see disturbances of person).
Dementia, simple, 433. Ekphoria, disturbances of, 12, 28.
Dementia senilis, treatment of, 278. Electricity as therapeutic agent, 222,
Dementia, traumatic, 241. Elementary hallucinations, 65.
Dementia, with mannerisms, 436. Embarrassment, 127.
Demonism, 150, 391, see Obsession. Emotional incontinence, 125.
Depersonalization, 142, 476. Emotional psychoses, 211.
Depression, 119. Emotional stupor, 80, 118, 163.
Depression, constitutional, 484. Encephalitis lethargica, 243.
Depression, reactive, 537. Endogenous causes, 173, 204.
Depressional, excited, 478. Enemies of society, 588.
Depressive delusion, 92. Engrams, 12, 28, 29.
Depressive delusion of disease, 92. Engraphic disturbances, 99.
Depressive dementia, 433. Epidemics, psychic, 211.
Depressive disposition, 485. Epilepsy, 332.
Depressive states, 161 ; in schizophrenia, Epilepsjr, alcoholic, 353.
410. Epilepsy, arteriosclerosis, 283, 286.
Depressive stupor, 476. Epilepsy, reactive, 459.
Dereistic thinking, 22, 45, 79. Epileptic associations, 82.
Determinism, 51, 52. Epileptic character, 449.-
Diagnosis of in&anit3', 184, 193. Epileptic equivalents, 443.
Differential diagnosis^ 193. Epileptic psychopathic constitution,
Dioning, 575, f.n. 449.
Dipsomania, 351, 586. Epileptic swindlers, 459.
Direction prognosis, 169. Epileptiform attacks, 445.
Discussion, capacity of, 438. Epileptiform attacks in arterioscle-
Displacement of the affects, 35, 36, 118, rosis, 283.
119, 499. Epileptiform attacks, occurrence, 199.
Disposition, 182. Epileptiform attacks, in presbyo-
Dissimulation, 192. phrenia, 296.
Dissociation, 86. E'quivalent epileptic attacks, 443.
Distractibility, 41 diminished in epi-
; Erethic oligophrenia, 605.
lepsy, 83; exaggerated in mania, Ereutrophobia, 127, 561.
71. Ethical materialism, 6.
Disturbances of activity, 142. Ethics, 52, 128, 148.
Disturbances of the impulses, 149. Euphoria, 122.
Disturbances of the person, 137. Exacerbations, 168.
Disturbances in writing, 155. Exaltation, 122.
Dizziness, epileptic, 448. Examination stupor = emotional stupor,
Double consciousness, 137. 80.
Double orientation, 383. Excitable, 582.
Double thinking, 63. Excited depression, 478.
Doubting mania, 561. Excitement, constitutional, 485.
Dream-like disturbances of association, Exhaustion, 123, 207; nervous, 557.
77. Exhaustion as cause of psychoses, 207.
Dreamy states, 165. Exhaustion stupor, 365.
Drinking mania, see Chronic alcohol- Exhaustive psychoses, 365.
ism. Exhibitionism, 573.
INDEX 629
Exogenous causes, 205. Hearing, disturbances of, 55.

Expansive delusion, 92. Hearing, hard of, deluwioHH of persecu-
Expansiveness, 92. tion, 533.
Expectation neurosis, 127, 165, 560. Hebephrenia, 426.
Explanatory delusions, 91. Hereditary syphilitic psychoses, 249.
Explosion readiness, 129. Heredity, 174, 200.
Extracampine hallucination, 60. Hesitancy in speech, 84.
Higher dementia, 616.
Familiarity, quality of, 31. Homilophobia, 461.
Family boasting, 450. Homosexuality, 575.
Family care, 219. Hunger for excitement, 129.
Family gossip, 450. Huntington's chorea, 243.
Family murder, 484. Hyoscine, 217, 224.
Fear of blushing, see Ereutrophobia. Hypalgesia, 57.
Fetichism, 494, 573. Hypasthesia, 57.
Fever delirium, 362. Hyperalgesia, 56.
Fever, psychogenetic, 543. Hypera-sthesia, 56.
Final thinking, 21. Hyperbulia, 144.
Flexibilitas cerea, 153, 403. Hyperkinesis, 146, 403, 411.
Flight into disease, 495. Hypermnesia, 97.
Flight of ideas, 71. Hypnogogic intoxication, 116.
Folie a deux, 534. Hypnosis, 44. 220.
Folie du doute, 561. Hypnotics, 222.
Folie raisonant, 468, 590, f. n. Hypochondria, 163, 436, 557.
Free floating affects, 36, 120. Hypochondriacal delusion, 92; in para-
Free will, 51. noia, 523.
Frenzy. 161, 468. Hypochondriacal neurasthenia in svph-
Friedmann's disease, 459. 245.
ilis,
Fright neurosis, 165, 564. Hysteria, see Psychopathic reaction

Fugues, see wandering mania. forms, 493, 540; traumatic, 566.
Hysterical, 436, 547.
Gait stuttering, 559. Hysterical amnesia, 546-547.
Gambling mania, 586. Hysterical associations. 84.
Ganser syndrome, 165, 545; in prison Hysterical attacks, 547. 554. 555.
psychoses, 536; in schizophrenia, Hysterical character, 552, 553.
412, 436. Hysterical conditions in syphilis, 245.
Genius, 171. Hysterical insanity, 547.
Germinal destruction, see Blastoph- Hysterical melancholia, 436, 547.
thoria, 203. Hysterical syndrome. 540.
Germinal hostility, 203. Hysterical twilight state, 544. 547.
Germinal predisposition, 200. Hystero-epilepsy, 552.
God-nomenclature, 450. Hysterophilic diseases, 498, 543.
Graft hebephrenia, graft schizophrenia,
437. Iatrogenic neuroses and psychoses, 502.
Grandiose delusions, 92; of paranoiacs Idealism, 5.
(495), 524. Ideas, 13; disturbances of, 68.
Gumma psychoses, 245. Identification. 499.
Gynandria, 577 f.n. Identifying memor\^ deceptions. 108.
Idiocy, 593; amaurotic, 243; following
Habits, 44 (494). traumas, 241.
Hallucinations, 59; diagnosis of, 187. Illusions, 58.
Hallucinatory confusion, 163, 436; trau- Imbecility, 593.
matic 241. Impotence, psychic, 127, 560.
Hallucinatory dementia, 434. Impressibility, 29; disturbances. 1(X);
Hallucinatory excitement, 142. examination, 188.
Hallucinosis, 163 acute in drunkards,
; Impulse, 11, 50-51; morbid. 148-149,
341 in syphilitics, 248.
; 562; examination of. 188.
Haptic sense deception, 64. Impulsives, 586.
Harmony, preestablished, 6. Impulsive actions. 149.
Head anxiety, 121. Impulsive insanity. 538.
Health conscience, 497. Impulsivities, schizophrenia, 409.
Health spite, 509. Inadequate affects. 154. 380.
630 INDEX
Incoherence, 86. Laughter, compulsive, 409.
Indeterminism, 51, 52. Lavage, 222. |t
Individuality, see person; disintegra- Lethal ending, 169.
tion of the individual. 141. Letter-wTiters. anonymous, 539.
Induced insanity, 212, 495, 534. Leukencephalitis of the corpus cal-
Infantilism, 165, 594. losum, alcoholic, 351.
Infection, psychic, 533. Liars, morbid, 587.
Infectious deliria, 363. Lissauer's paresis, 268.
Infectious insanity, 361. Litigious delusions. 166, 495, 521, 533;
Infectious states of weakness, 365. after accidents, 566; manic de-
Influenza deliria, 364. pressive, 487; paranoic, 521;
Inhibition, 79. schizophrenic, 414.
of action, 146. Logorrhea, 146, 468.
of development, 593. Loosening of the affects. 29.
Inhibitions of associations, 74, 373, 378; Loss of blood as cause of insanity, 207.
distinguished from obstruction, Lues cerebri, 244, 247.
79. Lumbar puncture, technique, 238.
Initial deliria in infectious diseases,
363. Malformations, 160.
Insane asylum, 216; for alcoholics, 324. Manhood as a disposition to psychoses,
Insanity, hysteric, 547. 212.
Instability, '582. Mania, 161, 465, 487.
Instincts, 52. Mania, anxious, 478.
Intelligence, 23; disturbances, see De- Mania ebriosa, 301 f.n.
mentia. Mania, hysterical, 436, 547.
Intelligence examination, 620. periodic, 483.
Intermissions, 168. poverty of thought in, 478, 479.
Internment in the insane asylum, 216. religiosa, 164.
Interpretateurs filiaux, 524. senilis, 289.
Intoxication, alcoholic, 300; senseless, Manic attack, appearance, 348.
300. Manic depressive insanity, 193, 372,
Involution, 212, 276. 465.
Involution melancholia, 488. Manic insanity, 162, 469.
Involution psvchoses, 211,^212. 276. Manic moods, 485.
Irritability, 123; abnormal, 582?""~~->- Manic state, 162; in schizophrenia,
Irritable mood, 485. 410.
Manic stupor, 479.
Jacksonian attacks, 166. Manic tendency, 485.
Jactation, 146. Manifestations of mental diseases, 161.
Joint reflexes, 158. Mannerisms, 142; in schizophrenia,
Joking mania. 241. 406.
Joy in pain, 502. Masochism, 574.
Judgment, 21 psychologic,
;
21. Mass epidemics, psychic, see psychic
Juvenile psychoses, 436; see Puberty epidemics.
psychoses. Mass psychology, 33.
Massage, 222.
Katathj'mic, 34. Masturbatic psychoses, 436.
Katathymic amnesias, 100. Masturbation, see Onanism.
Katathymic delusion, 91, 165. Materialism, 5.
Keraunophobia, 561. Maudlin drunkenness, 300.
Kleptomania, 149. Melancholia, 161, 472. 487.
Korsakoff, alcoholic, 345. 346; after car- Melancholia activa. 475.
bon monoxide, 299; in brain dis- agitata, 121, 475, 478.
eases, 241 in cocainism, 359.
; Melancholia attonita, 144, 163; in
Korsakoff, curable, 230. schizophrenia. 403.
Korsakoff's disease syndrome, 164, 165, Melancholia, hysteric, 547.
230, 241. involution, 488.
periodic, 483.
Lactation psychoses, 211. senilis, 289, 291.
Lacunary disturbances, 282. simplex, 476.
Latah, 153 f.n. Melancholic insanity, 162, 476.
Latent schizophrenia, 432. Melancholic moods, 485.
INDEX 631
Melancholic stato, 161 ; in Bchizo- Neurasthenia, 493, 552, 557, ft scq.;

phrcnia, 410. hypochondriacal in Hyphilitica,
Memory, 12, 28. 245.
Memory disturbances, 97; occurrence, Neurasthenia, sexual, 558.
196. Nf'iua.sthenia .yndromf-, 165, 493, 556.
Memory hulliKiinations, 106. Neura.sthenic association.s, 84.
Memory illusions, 106. Neunusthenic melancholia, 487.
Memory test, 188. Neurokym, 11 f.n.
Mendelian heredity, 201. Neuro.ses, 176, 493; see HyHteria, Neu-
Meningitis, 242. ra.sthenia, P.seudo-neura.-thenia.
Meningitis luica psychoses, 245. Nihilism, nihili.stic delusion, 93.
Menstrual disturbances, 127. Nonne, 239, 248, 254.
Menstrual psychoses, 210. Nutrition impulse, 148.
Menstruation, 210; cause of manic de- Nyctophobia, 561.
pressive attacks, 489, 539; of
psychoses, 210. Obedience, automatic, 152; in schizo-
Metabolic disturbances, 158. phrenia, 408.
Metabolism, 120. Obsession, see Impulsive insanity and
Metasyphilitic diseases, 250. Compulsion neurosis.
Micromania, 93. Obsessions, see Compulsion neurosis,
Micromelia, 372. differentiated from crowding of
Miryachit, 153 f.n. thoughts, 80.
Mistake and delusion, 90. Obsessive laughter, 409.
Mistaking of personality, 58; in mania, OKstruction, 79; of associations, 79.
469. Occupation as cause of insanity, 207.
Mongoloid, 372, 614. Occupation neuroses, 557.
Monideism, 74, 85, 119. Old age as cause of psychoses, 212.
Monism, 4. Oligophrenia, 593.
Monomania, 87 f.n., 403. Oligophrenic associations, 82.
Moods, constitutional, 485; epileptic, Oligophrenic, moral, see Moral idiocy.
132, 454 irritable as a permanent
; Omnipotence of thought, 561.
state, 484; manic, 122, 131, 485; Onanism, 127, 572.
melancholic, 119, 485; oligo- Onanism as causes of psychoses, 209.
phrenic, 606. Onanism, psychic, 573.
Moral, see ethics. Onanism, treatment of, 224.
Moral idiocy, 587. Onanism of necessity, 573.
Moral imbecility, see Moral idiocy. Oniomaniacs, see Buj'ing maniacs.
Moral insanity, 587; see Moral idiocy. Onomatomania. 561.
Moral oligophrenia, see Moral idiocy. Onsets, acute, 167.
Morbid euphoria, 122. Operations in the insane, 224; as cause
Morbid gain, 496. of mental disease, 211.
Moria, 161; following traumas, 241. Opiates, 223.
Morphine, see Opiates. Opiophagia, 359.
Morphinism, 354. Opium, see Opiates, 223.
Motilitj' psychoses, 436. Opium smokers, 359.
Multiple sclerosis, 230, 242. Organic, 173.
Mutism, 155; in schizophrenia, 394. Organic affectivity. 232, 233.
Mythology, 47. Organic associations, 74.
Myxedema, 366. Organic psychoses, 230.
Organic syndrome. 231.
Nanism, 372. Orientation, 32; disturbances, 110; oo
Nanosomia, 372. currence, 196.
Narcism, 573. Original morbid states. 569.
Narcolepsy, 459, 546. Original paranoia, 529.
Negative hallucinations, 44, 65. Otahspmatoma, 159.
Negative memory hallucinations, 101. Over-exertion. 207.
Negative suggestibility, 44; disturb- Over-valued ideas. 87.
ances of, 136.
Negativism, 154, 406. Pachvmeningitis Haemorrhagica, 268.
Nephritis, cause of amentia, 365. Parabulia. 148.
Nervosity, 571. Parasramatism. 397.
Nervous exhaustion, 557. Paraldehvde, 223.
632 INDEX
Parallelism, psycho-physical, 6. Piblokto, 459.
Paralyses, 157. Picae, 149.
Paralytic attacks, 254; occurrence, 199. Pithiatism, 502 f.n.
^J'aramnesias, 105, 108. Plaques senile, see Spherotrichia.
Paranoia, I'SS, 504, 509. Plasma cells (paresis), 267.
Paranoia, abortive, 528. Poetry, 47.
'
Paranoia, acute, IM, 487. Poison-mixers, 539.
Paranoia completa, 437, 529. Polioencephalitis superior, 350.
Paranoia-like diseases, 529. Ponopathies, 557.
Paranoia originaria, 529. Poriomania, 165, 586; see Wanderers.
Paranoia periodica, 487. Post-epileptic twilight states, 447.
Paranoia senilis, 292^' >^ Post-syphiliticdementia, 247.
Paranoiac associations, 83^ Potency, 159.
Paranoiac character, 532. Poverty of thought, 478.
Paranoid, 413. Precordial anxiety, 121, 472.
Paranoid constitution, 105^ Pregnancy as cause of the psychoses, 210.
Paranoid melancholia, 476. Premature birth, 225.
Paranoid mental weakness, 434. Presbyophrenia, 230, 277, 294.
Paranoid schizophrenia, 323<^ Presenile delusions, of injury, 279, 414;
Paranoid symptoms, 16V of pardon, 536.
.J'aranoid syndrome, 1S8. Presenile insanity, 276, 279.
Paraphrenias, 437. Pressure activity, pressure occupation,
Parasexuality, 574. 145, 334.
Parasthesias, 158. Primary dementia, 432.
Parathymia, 380. Primary diseases, 169.
Paresis, alcoholic, 350, Primary symptoms, 54.
Paresis, see dementia paralytica. Primitive reactions, 494, 497, 498, 537.
Patellar reflexes, test, 186. Primordial delusions, 91.
Pathological drunk, 300. Principal symptoms, 54.
Pavor noctumus, 116 Prison complex, 536.
Pederasty, 574. Prison outbreak, 535.
Pedophilia, 574. Prison psychosis, (126), 436, 535.
Perceptions, 10, 12; disturbances, 56; Prison syndrome, 535.
occurrence, 194. Prisoners' delusions, 536.
Periodic drinkers, see Dipsomania. Prisoners, mental disturbances in, 535.
Peruiodic insanity, see manic depressive Process psychoses, 173.
insanity. Prodromata, 167.
Periodic mania, 483. Prognosis, general, 169.
Periodic melancholia, 483. Progressive psychoses, 173.
Periodic neurasthenia, 487. Projection to the outside, 389.
Periodic paranoia, 487. Prophylaxis, 214.
Perivascular ghosis, 283. Pseudo dementia, 165, 545.
Persacutees persecuteurs, 527. Pseudo fiexibilitas, 153.
Perseveration, 57, 75, 83, 148; in schizo- Pseudo hallucinations, 69, 389.
phrenia, 81. Pseudo litigants, 592.
Person, personality, 49. Pseudologia phantastica, 108, 587.
Personal consciousness, 49. Pseudo neurasthenia, 504. 556, 557-558.^
Personality, annihililation of, 140; dis- Pseudo paresis, alcoholic, 350; syphi-
integration of, 141 disturbances
; litic, 247.
of, 137; dual, 3, 137; in arterio- Psyche, 1.
sclerotic insanity, 282; para- Psychiatry, significance of, 226.
phrenia, 436; schizophrenia, 436. Psychic hallucinations, 60.
Petit mal, 166, 448. Psychic scars, 169.
Phantasy, 22. Psychoanalysis, 501, 507.
Pharyngeal reflexes, 158. Psychogenic, 173.
Philosophv, 47. Psychogenic diseases, reaction forms,
Phobias, 88, 561. 493.
Phobo-phobia, 562. Psychokym, 11.
Physical complaisance, 499. Psychology of the masses, 43.
Physical delusion of persecution, 65; in Psychopathic forms of reaction, 493.
.schizophrenia, 390. Psvchopathic personahties, 570.
Physical symptoms, 157. Psychopathies, 164, (193), 504, 569.
INDEX 033
Psychotherapy, 220. 438; extent, 442.

diagno.sifl,
Puberty, causes of psychoses, 212. funflamental syriiptoin.s, 373,
Puberty, disposition to psychoses, 212. hallucination.'-:, .'187.
Puberty psychoses, 212. hebephrenia, 426.

Puerilism, i65, 535, 545. illusions, .388.
Puerperal fevers, cause of amentia, 365. intact functions, 384.
Puerperal psychoses, 210, 493. ]at(;nt Hchizophn.'nia, 4.32.
Pupillary reflexes, 186. memory, 383, .392.
Purpo.se p.sycho.ses, 165. mortality, 384.
Pyknical type, 177. orientation, 382-.3S3.
Pyromania, 149. paranoid, 413.
paranoid dementia, 434-436.
Querulance, 125. paraphrenias, 4.37.
pathology, 442.
Race, disposition to psychoses, 202, 203. perception, .383, 387.
Raptus, 143; melancholicus, 275. person, 385, 393.
Reactive epilepsy, 459. physical symptoms, 398.
Reactive psychoses, 173, (436) prognosis, 440.
Reality, 7. sensory deceptions, 387.
Reasoning mania, 88, 560. simple, 432.
Recognition of insanity, 184. simple functions, 373.
Reflection, 11. simplex, 433.
Reflex enforcement. 498. speech, 394.
Reflex hallucinations, 64; in schizo- subgroups, 413.
phrenia, 388. treatment, 443.
Reflex paralysis, traumatic, 565 f.n. unclearness, 412.
Reflexes, 158; differentiation from will, 385.
psyche, 1. writing, 394.
Relationship of the parents, 204. Scopolamine, see Hyoscine.
Religious delusion, 164. Second hearing, 390.
Remissions, 167, 168. Secondary delusion, 91.
Renifleurs,_574. Secondary dementia, 169.
Reo Nato, 592. Secondary diseases, 169.
Repression, 35, 37, 113-116, 501. Secondary insanity, 169.
Reduplicative memory deception, 109. Secondary sensations, 66.
Residual delusion, schizophrenia, 392. Secondary symptoms, 54.
Residual epilepsy, 459. Secretions, 159.
Restraint, 221. Sedobrol, 463.
Retrograde amnesia, 102. Selection of vocations, as prophylaxis^
215.
Sadism, 574. Self-consciousness, 49.
Schizoid, 175, 437, 441. Self-presei-vation impulse. 148.
Schizophasia, 155. Self-reference, 92, 95.
Schizophrenia, 155, 372. Senile dementia, see Dementia senilis.
accessory symptoms, 387. Senile insanity. 230, 276; treatment,
activitv, 386. 278; see Dementia senilis.
affectivity, 155, 378. Senile mania. 289. 291. 292.
ambitendency, 382. Senile melancholia. 289. 291. 292.
ambivalency, 382. Senile paranoia, 289, 291. 292.
anatomy, 442. Senile plaques, see Spherotrichia.
associations, 77, 373. Senile psychoses, see Senile insanity.
attention, 384. Senility as a cause of insanity, 212.
catatonia, 417. Sensations. 11, 12, 56.
catatonic symptoms, 403. Sense deceptions, 41; recognition of.
causes, 441. 187.
combinations, 437. Sensor>' organs, disturbances of, 55.
combined functions, 384. Separation from parents, 129.
concept, extent, 436. Sexual aberrations, 472.
course, 434. Sexual abstinence, causes of psychoses,
delusions, 390. 210.
dementia, 385. Sexual anomalies. 494. 572.
dereism, 384. Sexual anxiety, 119, 120.
634 INDEX
Sexual impulse, 52; disturbances of, Tension of the affects, 37-38.
572; in hysteria, (499-500), 544. Tertian Plasmodium malarise in the
Sexual neurasthenia, 458. treatment of paresis, 275.
Sexual relations, causes of psychoses, Theory of cognition, 3.
209. Thinking, 12, 17.
Shifts, 168. Thought crowding, 80, 152; in schizo-
Shop-lifters, 539. phrenia, 378.
Significance of psychiatiy, 226. Thought deprivation, 79, 378.
Simulation, 191. Thought hearing, 63.
Situation psychoses, 166, 493. Threats of suicide, 324 f.n.
Sleep disturbances, 158. Thymopaths, 117.
Sleeping sickness, 243. Thyreogenous psychoses, 365.
Snout cramp, 405-406. Tics, 152, 562.
Sodomy, 574. Torpor, 114.
Solipsism, 5, 6. Torticollis hystericus, 543.
Somatic approach, 499. Toxemias, acute, 299; chronic, 304.
Somnambulism, 88. Transference of affects, 35.
Somnifen therapy in schizophrenia, 444. Transformation of delusion, 94; of the
Somnolence, 114. personality, 139.
Sopor, 114. Transitivism, 138.
Speech confusion, 155, 434. Transitory psychoses, 163.
Spherotrichia, 277, 296. Traumatic delirium, 240.
Spirit of the times, 43. Traumatic dementia, 241.
Spitefid attitude, 128, 501. Traumatic epilepsy, 241, 457.
Squanderers, 586. Traumatic hysteria, 551, 566.
Status epilepticus, 448. Traumatic neuroses, 564.
Stealing impulse, see Kleptomania. Traumatic reflex paralysis, 564 f n. .
Steppage gait, 345. Traumatic states of weakness, 241.

Stereotypes, 147, 151; in schizophrenia, Traumatic twilight states, 241.
404, 408-409. Treatment of mental diseases, 214.
Sterilization, 214. Trembling, 157.
Stigmata in hysteria, 406. Tremor, 157.
Stomach neuroses, 485. Trional, 223.
Stupor, 126, 144; manic, 479; occur- Trophic disturbances, 158-159; in hys-
rence of, 198. teria, 543.
Stuporous dementia, 433. Tubular field of vision, 542.
Stuttering, 127, 452 f. n., 559. Turbid states, 114.
Stuttering in writing, 560. Turgor vitalis, 122.
Sublimation, 98. Twilight states, 112, 162, (494).
Submania, 467. Twilight states amnesias, 101, 102.
Suggestion suggestibility, 32; disturb- Twilight states, epileptic, 453.
ances of, 135; remedy of, 220. Twilight states, hysterical, 544.
Suicide, complicated, see Family murder. Twilight states, occurrence of, 198.
Sulfonal, 223. Twilight states, schizophrenic, 412.
Superstition, 48. Twilight states, traumatic, 241.
Swindlers, pathological, 587. Twins, insanity in, 200 f.n.
Symbol, 46, 70, 499.
Synasthesias, 66. Uncleanliness, 234.
Syndromes, 164. Unclear ones, 615.
Syntonic, 175; reaction types, 177. Uncleamess of the ideas, 26, 68; in oli-
Syntony, 174. gophrenia, 615.
Syphilitic pseudoparesis, see Pseudo- .Unconscious, 8, 502; collective, 33.
paresis. Uranism, 575 uming, 575 f n.
; .
Syphilitic psychoses, 244. Uremia, 191, 193; compare also amentia.
Tabes and ps5'choses, 249. Variation stereotypes, 147, 403-406.

Tabo-paresis, 249, 259. Vascular diseases, see Arteriosclerotic
Teliologic hallucinations, 62. insanity and luetic psychoses.
Temperaments, 35. Verbigeration, 146, 147; in schizo-
Temperature of body, 159. phrenia, 405.
Tenacity of attention, 40. Veronal, 223.
Tendon reflexes, 158. Vigility of attention, 40.
INDEX 635
Visions, 64. Wandering mania, 165; in hysteria

Vitamines, 207. (fugues; 446; in schizophrenia,
Vocation, selection of as prophylaxis, 413.
215. Weakness of will, 51.
Voices of conscience, 62, 387. Will, conception of, 52; disturbances
Voyeur, 574. 143-144; freedom of, 52.
of,
Word-salad, 155, 398.
Waking dreams, 546. Work as a therapy, 215; in schizo-
Wanderers, 586. phrenia, 444.
^
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UNIVERSITY

AUTHORIZED ENGLISH EDITION

A. A. BRILL, Ph.B., M.D.

THE MACMILLAN COMPANY

Setup and printed. Published January, 1924.

PRINTED IN THE UNITED STATES OF AMERICA BY

deep. It is therefore with a strong feeling of satisfaction that I present

numerous, so- -indefinite and 'so contradictory it was thought' best to

Hans W. Maier's paper on Eugen Bleuler, Zeitschr. f. d. gesammte Neurologie

countries. During his twenty-five years' service as a teacher at the

advance beyond the boundaries of the Kraepelinian psychiatry. To

1. Disturbances of the Centripetal Functions 55

11. Disturbances of Centrifugal Functions (Actions,

III Physical Symptoms 157

IV The Manifestations of Mental Diseases 161

V The Course of Mental Diseases 167

VI The Borderlines of Insanity 170

VII Classification of Mental Diseases 173

VIII The Recognition of Insanity 184

IX Differential Diagnosis 193

X Causes of Mental Diseases 200

XI The Treatment of Mental Diseases in General 214

XII The Significance of Psychiatry 226

XIII The Individual Mental Diseases 230

XIV Oligophrenias (Psychic Inhibitions of Development) . . 593

1. Paretic expression 251

THE PSYCHOLOGICAL PRINCIPLES ^

^Comp. Naturgeschichte der Seele, Springer, Berlin, 1921.

involved in expressions like "consciousness of time and place" for

The expression "dual consciousness" for "dual personality" is jut

Concerning the Theory of Cognition ^

Consciousness is said to differentiate psychic from physical occur-

^Disturbances of Personality, p. 137.

culty in this theory: It has to conceive everything as conscious

whether food has reality or not. Practically therefore, idealism

even accepted by those who theoretically advance another view. Of

revelation or the categorical imperative, or from other incomprehen-

Many view psycho-physical parallelism simply as a confirmation

will be impossible forme to prove it. The psychic series therefore

Psychoanalysts also differentiate a "psychic reality." This term is mis-

person. Here, besides the conscious mistaken identification, there

culties. Signs of an affect are frequently seen in normal persons, and

THE INDIVIDUAL PSYCHIC FUNCTIONS

independence and are rendered prominent as objects (trees, houses,

form of an image after perception.

a) The Centripetal Functions

as well as size and shape.

occurrence in former experiences, have a particularly fine coherence

b) Concepts and Ideas

forms the concept of this certain thing, this certain person.

and "effect" or in connection with the other relations of the things

Simultaneously with the perception of a thing or a process we

Concepts are not fixed; they are easily supplemented or trans-

In every concept formation, even the simplest, we see the activity

ideas; indeed, it comprises every tiling in so far as it can become actual

c) The Associations. Thought.

and these later inhibit the acquisition impulse as a simultaneous

gotten content of the ideas. And yet the associations accessible to

which in themselves or through their connections have a certain im-

been accustomed to write a letter of the alphabet in a certain man-

medical training does not make psychological thinking difficult because

it ignores but mainly because it forms associations in other direc-

tions and thereby virtually inhibits psychological thinking.